Provider Rights and Responsibilities

Provision of Covered Services
Providers will render covered services to Members within the scope of the provider’s business and practice, in accordance with the provider’s contract, Molina Healthcare’s policies and procedures, the terms and conditions of the Molina’s Dual Options product which covers the member and the requirements of any applicable government-sponsored program.

Standard of Care
Providers will render covered services to Members at a level of care and competence that equals or exceeds the generally accepted and professionally recognized standard of practice at the time of treatment, all applicable rules and/or standards of professional conduct and any controlling governmental licensing requirements.

Facilities, Equipment and Personnel
The provider’s facilities, equipment, personnel and administrative services should be at a level and quality necessary to perform duties and responsibilities in order to meet all applicable legal requirements including the accessibility requirements of the Americans with Disabilities Act.

When a provider determines that it is medically necessary to consult or obtain services from other specialty health professionals, the provider should make a referral in accordance with Section VIII – Utilization Management, Section T – of this Manual unless the situation is one involving the delivery of emergency services. Providers should coordinate the provision of specialty care in order to ensure continuity of care. Providers need to document referrals that are made in the patient’s medical record. Documentation needs to include the specialty, services requested and diagnosis for which the referral is being made.

Contracted Providers
Except in the case of emergency services or after receiving prior authorization of Molina Healthcare, providers should direct Members to use only those health professionals, hospitals, laboratories, skilled nursing and other facilities and providers, which have contracted with the Molina Dual Options Plan.

Member Eligibility Verification
Providers should verify eligibility of Molina Members prior to rendering services.

Providers are required to comply with Molina Healthcare's facility admission and prior authorization procedures.

Providers are required to abide by Molina Healthcare drug formularies and prescription policies, including those regarding the prescription of generic or lowest cost alternative brand name pharmaceuticals. Providers should obtain prior authorization from the Molina Healthcare Pharmacy Department if the provider believes it is necessary to prescribe a non-formulary drug or a brand name drug when generics are available.
The only exceptions are prescriptions and pharmaceuticals ordered for inpatient facility services. Molina Healthcare’s contracted pharmacies/pharmacists may substitute generics for brand name pharmaceuticals unless counter indicated on the prescription by the provider.

Subcontract Arrangements
Any subcontract arrangement entered into by a provider for the delivery of covered services to Members must be in writing and will bind the provider’s subcontractors to the terms and conditions of the provider’s contract including, but not limited to, terms relating to licensure, insurance, and billing of Members for covered services.

Availability of Services
Providers must make necessary and appropriate arrangements to assure the availability of covered services to Members on a twenty-four (24) hours a day, seven (7) days a week basis, including arrangement to assure coverage of member visits after hours. Providers are to meet the applicable standards for timely access to care and services as outlined in this manual in Chapter VI – Quality Improvement, taking into account the urgency of the need for the services.

Treatment Alternatives and Communication with Members
Molina Healthcare endorses open provider-member communication regarding appropriate treatment alternatives and any follow up care. Molina Healthcare promotes open discussion between provider and Members regarding medically necessary or appropriate patient care, regardless of covered benefits limitations. Providers are free to communicate any and all treatment options to Members regardless of benefit coverage limitations. Providers are also encouraged to promote and facilitate training in self-care and other measures Members may take to promote their own health.

Providers will not differentiate or discriminate in providing covered services to Members because of race, color, religion, national origin, ancestry, age, sex, marital status, sexual orientation, physical, sensory or mental handicap, socioeconomic status, or participation in publicly financed healthcare programs. Providers are to render covered services to Members in the same location, in the same manner, in accordance with the same standards and within the same time availability regardless of payer.

Maintaining Member Medical Record
Providers are to maintain an accurate and readily available medical record for each member to whom health care services are rendered. Providers are to initiate a medical record upon the member’s first visit. The member’s medical record should contain all information required by state and federal law, generally accepted and prevailing professional practice, applicable government sponsored health programs and all Molina Healthcare’s policies and procedures. Providers are to retain all such records for at least ten (10) years.

Confidentiality of Member Health Information
Providers are expected to comply with all applicable state and federal laws. Refer to Chapter VII for HIPAA requirements and information.

HIPAA Transactions
Providers are expected to comply with all HIPAA TCI (transactions, code sets, and identifiers) regulations. Refer to Chapter VII for HIPAA requirements and information.

National Provider Identifier (NPI)
Providers are expected to comply with all HIPAA NPI regulations. Refer to Chapter VII - HIPAA requirements and information.

Delivery of Patient Care Information
Providers are to promptly deliver to Molina Healthcare, upon request and/or as may be required by state or federal law, Molina Healthcare’s policies and procedures, applicable government sponsored health programs, Molina Healthcare’s contracts with the government agencies, or third party payers, any information, statistical data, encounter data, or patient treatment information pertaining to Members served by the provider, including but not limited to, any and all information requested by Molina Healthcare in conjunction with utilization review and management, grievances, peer review, HEDIS Studies, Molina Healthcare’s Quality Improvement Program, or claims payment. Providers will further provide direct access to patient care information as requested by Molina Healthcare and/or as required to any governmental agency or any appropriate state and federal authority having jurisdiction. Molina Healthcare will have the right to withhold compensation from the provider in the event that the provider fails or refuses to promptly provide any such information to Molina Healthcare.
CMS has specific guidelines for the retention and disposal of Medicare records. Please refer to CMS General Information, Eligibility, and Entitlement Manual, Chapter 7, Chapter 30.30 for guidance.

Member Access to Health Information
Providers are expected to comply with all applicable state and federal laws. Refer to Chapter VII for HIPAA requirements and information.

Participation in Grievance Program
Providers are expected to participate in Molina Dual Option’s Grievance Program and cooperate with Molina Healthcare in identifying, processing, and promptly resolving all member complaints, grievances, or inquiries. If a member has a complaint regarding a provider, the provider will participate in the investigation of the grievance. If a member appeals, the provider would participate by providing medical records or statement if needed. Please refer to Chapter XIV regarding members’ appeals and grievances.

Participation in Quality Improvement Program
Providers are expected to participate in Molina Healthcare’s Quality Improvement Program and cooperate with Molina Healthcare in conducting peer review and audits of care rendered by providers.

Participation in Utilization Review and Management Program
Providers are required to participate in and comply with Molina Healthcare’s utilization review and management programs, including all policies and procedures regarding prior authorizations, and Interdisciplinary Care Teams (ICTs) . Providers will also cooperate with Molina Healthcare in audits to identify, confirm, and/or assess utilization levels of covered services.

Participation in Credentialing
Providers will participate in Molina Healthcare’s credentialing and re-credentialing process and will satisfy, throughout the term of their contract, all credentialing and re-credentialing criteria established by Molina Healthcare. The provider is to immediately notify Molina Healthcare of any change in the information submitted or relied upon by the provider to achieve credentialed status. If the provider’s credentialed status is revoked, suspended or limited by Molina Healthcare, Molina Healthcare may, at its discretion, terminate the contract and/or reassign Members to another provider.

The delegated entities will accept delegation responsibilities at Molina Healthcare’s request and shall cooperate with Molina Healthcare in establishing and maintaining appropriate mechanisms within the provider’s organization. If delegation of responsibilities .is revoked, Molina Healthcare will reduce any otherwise applicable payments owing to the delegated entity. Delegated services may include but not be limited to Claims, Utilization Management, Credentialing, and certain administrative functions that meet the criteria for delegation.
Delegated entities shall comply with all state and federal requirements including but not limited to:

  • Reporting
  • Timeliness standards for organizational determinations
  • Training and education


Provider Manual
Providers will comply and render covered services in accordance with the contents, instructions and procedures as outlined in this manual, which may be amended from time to time at Molina Healthcare’s sole discretion.

Health Education/Training
Providers are to participate in and cooperate with Molina Healthcare provider education and training efforts as well as member education and efforts. Providers are also to comply with all Molina Healthcare’s health education, cultural and linguistic standards, policies, and procedures.

Promotional Activities
At the request of Molina Healthcare, the provider may display Molina Healthcare promotional materials in its offices and facilities as practical, and cooperate with and participate in all reasonable Molina Healthcare marketing efforts. Providers shall not use Molina Healthcare’s name in any advertising or promotional materials without the prior written permission of Molina Healthcare.
Providers are responsible for complying with all Marketing Guidelines. The provisions that apply to providers are identified in the Guidelines. CMS periodically updates and revises the Guidelines. Providers will cooperate with Molina and comply with the HFS Managed Care Health Plan Marketing Guidelines Providers should keep apprised of any updates that are issued by CMS. For your convenience, we have provided the following link to CMS’s website: