Claims Submission

As a participating provider with MCC, 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, MCC 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 Participating Provider Agreement.

  • Reimbursement of Covered Services

    As a participating MCC provider, you agree to bill all covered services provided to MCC members on the required forms and/or electronic claims file format. All claims should be billed on a fully completed CMS 1500, UB04 and/or CMS 1450 to be considered for adjudication and/or payment. You may visit the Centers for Medicare and Medicaid Services (CMS) website at www.cms.hhs.gov to obtain more information about these forms and/or for more instruction and/or information on the proper use of claims forms for services.

    Any claims requiring authorization should include the authorization number in the appropriate field of the CMS 1500, UB04 or CMS 1450 to assist with appropriate claims processing and timely claims payment. Download this list of services requiring prior authorization (coming soon). A reference to the listing is also located in Section 10: Medical Management of the MCC provider manual.

  • How do I submit my claims to MCC?

    You can submit your claims to MCC by paper or electronically. You are strongly encouraged to submit your claims electronically. Electronically transmitted claims result in faster claims payment turnaround times and higher acceptance rates. However, if you choose not to bill electronically, we can accept paper claims.

    Submitting Electronic Claims

    Molina uses Change Healthcare as its gateway clearinghouse. Change Healthcare has relationships with hundreds of other clearinghouses. There are several other claims clearinghouses that we work with. Please call Customer Care to check if Molina has a relationship with your clearinghouse. MCC’s clearinghouse payer ID for both Medicare and Medicaid claims is MCC02. The MCCVA Payer ID will no longer be accepted effective 7/1/2022.

    Effective 7/1/2022, MCC offers a direct submit/web-based claims option through Availity to Molina for both Medicaid and Medicare claims. This functionality is available via the provider portal on our website. There is no charge to participating providers for submitting claims through the Availity tools. Availity supports keyed entry of claims on the portal and supports secure transfer/upload of batch claim files from most practice management systems. You must register with Availity to use the service and add Molina Healthcare Virginia as one of your payers. If you are not currently registered with Availity please visit www.availity.com to get connected.

    For Medicaid claims, DOS 7/1/2022 and forward must use Payer Name Molina Healthcare of Virginia. For DOS prior to 7/1/2022, web-based claims can still be submitted through Availity using Payer Name Molina Complete Care – Medicaid.

    Submitting Paper Claims

    Participating Providers should submit Claims electronically. If electronic Claim submission is not possible, please submit paper Claims to the following address:

    Molina Healthcare of Virginia, LLC
    PO Box 22656
    Long Beach, CA 90801

    Please keep the following in mind when submitting paper Claims:

    • - Paper Claims should be submitted on original red colored CMS 1500 Claims forms.
    • - Paper Claims must be printed, using black ink.

     

  • Timely Filing of Claims

    Claims for services provided to MCC 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 MCC 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 MCC takes under consideration:

    • Coordination of benefits—When an MCC 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 MCC receives notification from the enrollment broker of the member’s enrollment.
    • Other (good cause)—MCC 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 MCC provider manual.