Claims Submission

As a participating provider with Molina, you have established a contractual agreement to provide physical, behavioral and/or other long-term support services to our members. The arrangement is fee-for-service for the provision of covered healthcare services unless otherwise specified under your Participating Agreement. The rates established in your Participating Agreement are considered full payment for covered services provided. Accordingly, Molina members may not be balance billed for any remaining amounts and/or difference between what is billed, and your negotiated reimbursement rates defined in the rate exhibit of your P
articipating Provider Agreement.

  • Timely Filing of Claims

    Claims for services provided to Molina members should be submitting within six months (180 days) of the date of service unless otherwise agreed upon in the Participating Provider Agreement. If not otherwise defined in the Participating Agreement, and/or in the case of a non-participating provider who provides covered service to Molina members, claims must be received within twelve months (365 calendar days) to be considered for processing and payment.

    There are three timely filing exceptions that Molina takes under consideration:

    • Coordination of benefits—When an Molina member has a primary insurance, the primary insurance Explanation of Payment (EOP) or Medicare Summary Notice (MSN) is used to determine the timely filing deadline. For these claims, the time frame begins with the print date on the primary insurance EOP or MSN.
    • Members with retroactive eligibility—When a member becomes eligible for a DMAS Medicaid program after the date of service, but their coverage is backdated to include the date of service, the time frame for timely filing begins on the date Molina receives notification from the enrollment broker of the member’s enrollment.
    • Other (good cause)—Molina will consider exceptions on a case by case basis for other causes of filing delays, such as incorrect information provided by official sources.

    Corrected claims, adjustments, or reconsiderations should be submitted within 180 days of the original claim paid date in order to be considered for reprocessing.

    Processing and payment of claims for covered services are generally made within 30 calendar days of receipt of a clean claim. For more information on claims submission and payment, please refer to the Molina provider manual.