Working with us

We’re committed to offering our Senior Whole Health Medicare Complete Care (HMO D-SNP), Senior Whole Health NHC (HMO D-SNP) and SCO members access to quality providers in their communities, and we want you to join us!

  • Checking member eligibility

    Individuals are eligible for Senior Whole Health plans if they:

    • Are 65 years old or older
    • Have Medicare & MassHealth Standard (dual eligible) or have MassHealth Standard
    • Live in our service area

     

    To check member eligibility: please log into our provider portal.

    Follow these instructions to register on the provider portal.

    Link to PDF on how to register for provider portal

    The most efficient way to check member eligibility is through one of the following online tools:

    • NewMMIS, formerly known as REVS
      • Log in to Provider Online Service Center (POSC)*
        • Click Manage Members/Eligibility, and look up patient by SSN or name and DOB
        • In the List of Managed Care Data (for MCO) section, choose Senior Whole Health
      • Registration is free for MassHealth Providers
      • For registration and other information, visit Mass.gov/masshealth* or call
        1-800-841-2900 (this number may also be used to access the IVR system)
    • NEHEN, New England Healthcare EDI Network
      • Log in to
        • Under Payer, select Medicaid
        • In the Additional/Alternate Payer section, choose Senior Whole Health under Managed Care Coordinator
      • Available at no cost to NEHEN members
      • For information, visit NEHENNet.org* or call 781-290-1290

     

    Advantages to using these online tools:

    • Prompt, 24/7 access
    • Unlimited number of inquiries
    • Ability to confirm single dates of service and date ranges
    • Easily print eligibility confirmation for your records

     

    You can also call SWH of MA Eligibility at 1-855-838-8002 for assistance.

    *By clicking this link you will be leaving the Senior Whole Health website.

  • Member Benefit Information

    We cover benefits provided by network providers without referrals.

    For a complete list of member benefits, limitations and requirements, please refer to the Senior Whole Health Evidence of Coverage and Summary of Benefits

    For medical services requiring prior authorization, complete the Standard Prior Authorization Request Form (coming soon) and fax it to our confidential Clinical Department fax line at 617-494-5554 or 508-823-6375. We will give you’re a decision within 14 calendar days unless we need additional information.

    All inpatient authorization requests must include clinical information. You may call in the clinical information to 617-252-6357.

    To get prior authorization for prescription drugs, you may request coverage:

    More information on concurrent and retroactive authorizations is available in the Provider manual.

    You may use the means above to request Formulary exceptions, including asking for a drug not listed on the formulary or to waive a restriction such as quantity limits, prior authorizations and step therapy.

  • Reporting Fraud, Waste and Abuse

     

    Senior Whole Health encourages providers to report fraud or suspected fraud by calling the Molina AlertLine: Call: 1-866-606-3889 TTY: 711 (for the hearing impaired) Online: https://molinahealthcare.alertline.com.

     

    For more information on fraud, waste and abuse, refer to your provider manual
  • Submitting provider rosters and other changes to provider information

    How to submit provider rosters and roster updates

    Please read the following rules and guidelines for submitting rosters and roster updates.

    • All provider rosters submitted for processing must include a complete listing of par providers associated with:
      • Participating group practices of 5 or more providers
      • IPAs
      • Hospitals and hospital systems
      • PHOs, IDNs and other contractual relationships that include multiple providers (practitioners and/or facilities)
    • To comply with CMS and state Medicaid regulatory requirements, providers should submit full roster updates on a quarterly basis (once every 3 months)
    • Interim roster updates/changes can be submitted on a monthly basis and must contain a minimum of 5 affiliated providers.

    Updates submitted for fewer than 5 providers will not be accepted. Please see the section titled How to submit provider maintenance tasks for updates to individually contracted providers and groups of fewer than 5.

    • All provider rosters and provider roster updates must be submitted using the Excel spreadsheet template below and include all the required data elements.

    Senior Whole Health Roster Template

    • Any roster, roster update or provider data maintenance request that does not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
    • Completed requests should be saved using the following file naming conventions: <provider name_date>.xls

    Example file names:
    Group Practice: ABCPediatrics_01012020
    Health System, IPA, PHO: BaptistHealthSystem_01012020

    • Email completed rosters, roster updates and provider data maintenance files/forms to SWHProviderRelations@molinahealthcare.com.
    • All provider rosters, roster updates and data maintenance tasks including the required data elements will be processed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.

    How to submit provider maintenance tasks

    Individually contracted providers (solo practitioners/facilities) and group practices with fewer than 5 providers can update their demographic information by submitting a provider maintenance task.

    • Provider maintenance tasks can be submitted each month (as needed) by downloading and completing the following Excel spreadsheet template.

    Senior Whole Health Roster Template

    • Provider data maintenance tasks that do not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
    • Completed requests should be saved using the following file naming conventions.

    Example file names:
    Individual Provider: JohnSmith_01012020
    Small Group Practice: ABCPediatrics_01012020

    Please note groups must be less than 5 providers

    • Email provider data maintenance files/forms to SWHProviderRelations@molinahealthcare.com.
    • All provider data maintenance forms will be completed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.