Definitions
Peer-to-Peer: The provider directing the care of the member requests to speak to a Medical Director regarding an adverse determination and potentially provides additional verbal information. Peer-to-Peer is a conversation. For additional details, refer to your Provider Manual.
Authorization Appeal: Formerly known as an “authorization reconsideration.” A provider dispute for the denial of a prior authorization. The Authorization Appeal must be submitted pre-claim. The Authorization Appeal should be submitted on the Availity provider portal. Once the claim is on file, providers must follow the Clinical Claim Dispute process.See your Provider Manual for more information.
Clinical Claim Dispute: Formerly known as an “authorization reconsideration.” A post-claim provider dispute for the denial of a prior authorization or for the denial of a retro-authorization for Extenuating Circumstances. The Clinical Claim Dispute must be submitted on the Authorization Reconsideration Form (Authorization Appeal and Clinical Claim Dispute Request Form). The Clinical Claim Dispute must be post-claim. Providers may submit a Clinical Claim Dispute via Availity provider portal, fax or verbally by calling the Provider Services Contact Center. Review your Provider Manual for additional details.
External Medical Review (Medicaid/MyCare only): After exhausting Molina’s Authorization Appeal or Clinical Claim Dispute process, a provider may request an External Medical Review (EMR) if the authorization or claim denial, limitation, reduction, suspension, or termination was based on medical necessity. For more information on EMR, please see the Utilization Management section of your Provider Manual.
Non-Clinical Claim Dispute: Formerly known as a “claim reconsideration.” This process is used only for disputing a payment denial, payment amount, or a code edit. The Non-Clinical Claim Dispute must be submitted on the Claim Reconsideration Form (Non-Clinical Claim Dispute Form). Providers may submit a Non-Clinical Claim Dispute via the Availity provider portal, fax, or verbally by calling the Provider Services Contact Center. Review your Provider Manual for more information.
Molina Healthcare of Ohio Inc.’s Processes by Line of Business.
Provider Claim Disputes
Medicaid, MyCare and Medicare providers seeking a redetermination of a claim previously adjudicated must request such action within 365 days from the date of service or 60 days from the date of the original remittance advice, whichever is greater. For Marketplace providers, a claim reconsideration must be submitted within 120 calendar days from the disputed claim remit date. Providers should clearly mark the items being resubmitted as “redetermination” and must include the following documentation:
Provider shall classify these requests as Claims Disputes/Adjustment and submit them via the Availity provider portal, by fax or verbally by calling (855) 322-4079. You can find additional details in your Provider Manual.
Molina will notify the Provider of the decision in writing within 30 days for clinical claim disputes and 60 days for non-clinical claim disputes. Providers may request a claim dispute/adjustment when Molina incorrectly denied the claim as duplicate, or due to claims examiner or data-entry error.
Member Appeals Represented by the Provider
For information on Member Appeals Represented by the Provider, please refer to your Provider Manual.