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Welcome, South Carolina Healthcare Providers

Contracted providers are an essential part of delivering quality care to our members. We value our partnership and appreciate the family-like relationship that you pass on to our members. As our partner, assisting you is one of our highest priorities. We welcome your feedback and look forward to supporting all of your efforts to provide quality care.

If you have any questions, please call Provider Services at (855) 237-6178.

Find out more about how Molina can be a resource to providers by clicking on the video below. 

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Provider Dispute and Appeals Submissions

Molina has gone green and is requesting that all providers submit provider dispute and appeals electronically. Electronic submission provides benefits to providers including faster disputes and appeals processing, increased overall efficiencies, improved processing accuracy and reduced HIPAA violations.

Any disagreement regarding the processing, payment or non-payment of a claim is considered a provider dispute. Provider disputes are typically disputes related to overpayment, underpayments, untimely filing, missing documents (i.e., consent forms, primary carrier explanation of benefits) and bundling issues. Provider Appeals are requests related to a denial of an authorization or medical criteria. A provider has 90 days from date of remittance denial to dispute a claim.

Molina offers the following submission options:

  • Submit requests directly to Molina Healthcare of South Carolina via Availity at: Provider.MolinaHealthcare.com
  • Submit requests directly to Molina Healthcare of South Carolina via fax at (877) 901-8182
  • Submit Provider Disputes through the Contact Center at (855) 882-3901
  • Submit requests via mail to:
Molina Healthcare of South Carolina
Provider Dispute and Appeals
PO Box 40309
North Charleston, SC 29423-0309

Important Information

  • Click here to find out more about Optum prepay.
  • Molina has incorporated American College of Radiology (ACR) guidelines into Molina's criteria of clinical decision support for advanced imaging. For more information contact Provider Services at (855) 237-6178 or email at SCProviderServices@MolinaHealthcare.com
  • Please notify Molina Healthcare at least 30 days in advance when you have any of the following: Change in office location, office hours, phone, fax, or email; Addition or closure of office location; Addition or termination of a provider; Change in Tax ID and/or NPI; Open or close your practice to new patients (PCPs only)

Provider and Member Rights and Responsibilities

As a contracted provider with Molina Healthcare, all participating providers are expected to adhere to a set of responsibilities. To review these provider responsibilities, please refer to the Molina Healthcare Provider Manual.
 
For your reference, we have also included Molina’s Member Rights and Responsibilities as a section in the Provider Manual. As a Molina provider, you and your staff agree to follow and comply with Molina’s administrative, medical management, quality assurance, and reimbursement policies and procedures.

Fax Size Submission Update for Clinical Information

As of May 1, 2023, the maximum clinical information fax size threshold Molina Healthcare can accept is no more than 100 pages (10 MB) for the total size of the fax transmission. Anything over the 100-page (10 MB) threshold will fail.
 
Molina requires copies of current and relevant clinical information to be submitted for documentation to ensure accurate and timely clinical decision-making. Clinical information includes but is not limited to pertinent physician emergency department notes, inpatient history/physical exams, discharge summaries, physician progress notes, physician office notes, nursing notes, results of laboratory or imaging studies, therapy evaluation, and therapist notes.
 
Molina does not accept telephone summaries or inpatient Care Manager criteria reviews as meeting the clinical information requirements unless state or federal regulations allow such documentation to be accepted. Providers are required to interact with Molina's Healthcare Services Department electronically whenever possible. Providers can submit requests via the Availity Essentials Provider Portal. Providers may also find training and other resources on the Availity Essentials platform. If there is a complex or extenuating clinical situation, please do not hesitate to contact the Healthcare Services Department or your Provider Services Team for further review and resolution.
 

Prior Authorization Updates

Prior Authorization Code Matrix

Code Matrix Reference Information

Diagnosis Code Reference Guide

Prior Authorization Guide

Prior Authorization Request Form

Behavioral Health Prior Authorization Form

Quick Links

Provider Online Directory

Availity

Provider Manual

Frequently Used Forms / Resources

Provider Newsletters

Site of Care Drug List

On 1/1/2021, Molina implemented a Site of Care policy for Medicaid and Marketplace that may result in a change in the place of service for certain medically necessary provider-administered medications (HCPCS J Codes). These medications are required to be rendered in the most appropriate setting, such as home or independent infusion centers (place of service 11 or 12), and not in a hospital setting unless it meets medically indicated exceptions. Click here for the complete list and more information that includes the medications and classes that will be impacted by this change. 

Are You ADA Compliant?

The Americans with Disabilities Act requires access to the facilities where medical services are provided. As a provider, you are required to inform Molina Healthcare of South Carolina Network Administration here if you are not ADA compliant or handicap accessible and provide what alternative accommodations are being offered to our members.