Important provider resources and policies
For all your Non-Emergent Medical Transportation (NEMT) needs, please contact Veyo at (800) 424-4524 for CCC Plus members, and (800) 424-4518 for Medallion 4.0 members.
Molina encourages electronic payment of your claims remittance. In order to get your claims payment direct deposited into your bank account, please complete and return this enrollment form, along with all requested documentation within the form. Return the documentation to MCCVA-Provider@MolinaHealthcare.com.
- Submitting provider rosters and other changes to provider information
How to submit provider rosters and roster updates
Please read the following rules and guidelines for submitting rosters and roster updates.
- All provider rosters submitted for processing must include a complete listing of par providers associated with:
- Participating group practices of 5 or more providers
- IPAs
- Hospitals and hospital systems
- PHOs, IDNs and other contractual relationships that include multiple providers (practitioners and/or facilities)
- To comply with CMS and state Medicaid regulatory requirements, providers should submit full roster updates on a quarterly basis (once every 3 months)
- Interim roster updates/changes can be submitted on a monthly basis and must contain a minimum of 5 affiliated providers.
Updates submitted for fewer than 5 providers will not be accepted. Please see the section titled How to submit provider maintenance tasks for updates to individually contracted providers and groups of fewer than 5
- All provider rosters and provider roster updates must be submitted using the Excel spreadsheet template below and include all the required data elements.
- Any roster, roster update or provider data maintenance request that does not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
- Completed requests should be saved using the following file naming conventions: [provider name_date].xls
- Example file names:
- Group Practice: ABCPediatrics_01012020
- Health System, IPA, PHO: BaptistHealthSystem_01012020
- Email completed rosters, roster updates and provider data maintenance files/forms to MCCVA-Provider@MolinaHealthcare.com.
- All provider rosters, roster updates and data maintenance tasks including the required data elements will be processed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.
How to submit provider maintenance tasks
Individually contracted providers (solo practitioners/facilities) and group practices with fewer than 5 providers can update their demographic information by submitting a provider maintenance task.
- Provider maintenance tasks can be submitted each month (as needed) by downloading and completing the following Excel spreadsheet template.
- Provider data maintenance tasks that do not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
- Completed requests should be saved using the following file naming conventions.
- Example file names:
- Individual Provider: JohnSmith_01012020
- Small Group Practice: ABCPediatrics_01012020
- Please note groups must be less than 5 providers
- Email provider data maintenance files/forms to MCCVA-Provider@molinahealthcare.com.
- All provider data maintenance forms will be completed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.
- All provider rosters submitted for processing must include a complete listing of par providers associated with:
- Filing an appeal with Molina
Provider appeals are requests made by the Molina providers (in-network and out-of-network) to review Molina's adverse benefit determination in accordance with the statutes and regulations governing the Virginia Medicaid appeal process. After a provider exhausts Molina's internal appeal process, Virginia Medicaid affords the provider the right to two (2) administrative levels of appeal (informal appeal and formal appeal) in accordance with the Virginia Administrative Process Act (Code of Virginia Section 2.2-4000 et seq.) and Virginia Medicaid’s provider appeal regulations (12 VAC 30-20-500 et seq.).
Providers may submit reconsiderations to Molina if a provider has rendered services to a member and has been denied authorization/reimbursement for services or has received reduced authorization/reimbursement.
A provider may file an appeal with Molina within 60 calendar days from the date of the adverse benefit determination notice/remittance advice. Failure to file an appeal with Molina within this time frame shall result in an administrative dismissal.
A provider must file the appeal with Molina in writing, although the appeal may be started verbally. The appeal must identify the issues, adjustments, or items the provider is appealing and include any supporting documentation, which explains or satisfies the reason for the original denial and why it should be paid accordingly.
There are several ways to file an appeal:
- By phone
- Call Customer Care Monday through Friday from 8 a.m. to 6 pm. local time. Providers may leave a message after hours that will be returned the next business day.
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518
- Call Customer Care Monday through Friday from 8 a.m. to 6 pm. local time. Providers may leave a message after hours that will be returned the next business day.
- By mail
- Send your appeal request to:
Molina Healthcare
Attn: Complaint Coordinator
PO Box 36030
Louisville, KY 40233-6030
- Send your appeal request to:
- By secure email
- By fax
Download a copy of our Appeals Form.
For more information about provider appeals, refer to your provider manual.
- By phone
- Fully integrated model of care
Molina delivers a fully integrated model of care specially designed for members of Virginia’s Commonwealth Coordinated Care Plus (CCC Plus) and Medallion 4.0 programs.
Our model improves the health status of Virginians by developing person-centered care coordination delivered through Integrated Health NeighborhoodSM teams that integrate community resources and non-traditional services within local health systems. We work to ensure that natural and peer supports, housing and employment are in place, in addition to traditional behavioral and medical treatment.
Our providers are the key to our success in delivering person-centered care. Together, we can leverage our strength, experience and expertise to improve outcomes for individuals in need of comprehensive care.
Integrated Health NeighborhoodsSM
Our exclusive Integrated Health Neighborhood model helps keep our members connected to their families, friends, neighbors, healthcare providers and other connections. These can include work, school, faith communities and social support groups and services.
Our care teams include individuals who live and work in the same communities as our members. They are familiar with the local resources and services that can benefit our members the most and provide our members with choices in their neighborhood and community. Community team members include Care Managers, health guides, recovery support navigators, community outreach specialists, employment specialists, medical directors and others.
This Integrated Health Neighborhood model drives close collaboration with community partners, enhancing our ability to provide person-centered care to our members. It naturally bridges language and cultural barriers, and efficiently facilitates access to services to support our families where they live and work.
- Member information
When a new CCC Plus member (or Medallion 4.0 member who we determine has healthcare needs that require care coordination) enrolls with Molina, we will conduct an initial Health Risk Assessment to determine the member’s needs and complete an initial individualized care plan (ICP), which includes but is not limited to, the member’s expressed goals, services the member needs and will receive (regardless of payer source), and the member’s preferences for their care and provider selection.
Upon enrollment, each Molina member receives a member ID card reflecting his/her primary care provider (PCP) name and effective date. The Molina Member Services number is located on the back of the ID card.
For information about member benefits or eligibility please refer to our For Members section.
Individualized care plans for members
Molina's model of care is person-centered, community-focused, and evidence-driven. We focus on activities designed to improve quality of life and health outcomes by targeting and influencing behavioral, social, economic, and clinical determinants of those outcomes at both the individual and group level.
This individualized, person-centered approach engages individuals with disabilities and chronic conditions to effectively interact with the provider delivery system to ensure choice, control, and access to a full array of quality services. This approach ensures optimal outcomes such as independence, health and wellness, and quality of life.
Our Care Managers work to develop an ICP with CCC Plus members and any Medallion 4.0 members whose needs require care management.
- Member rights & responsibilities
Below is the link to the Molina Healthcare rights and responsibilities as written in the Molina Member Handbooks. Virginia Law requires that health care providers or health care facilities recognize member rights while they are receiving medical care and that members respect the health care provider's or health care facility's right to expect certain behavior on the part of patients.
Molina Healthcare Member Rights & Responsibilities Statement
- Providers responsibilities
Molina Network provider participation
Molina Healthcare is dedicated to selecting healthcare professionals, groups, agencies and facilities to provide member care and treatment across a range of covered services as defined by Virginia Department of Medical Assistance Services (DMAS).
To be a network provider of health care services with Molina under the CCC Plus and Medallion 4.0 programs, you must be credentialed and contracted according to Molina and DMAS standards. Providers are subject to applicable licensing requirements. You have the right to request the status of your credentialing or recredentialing application.
Your responsibilities
Your responsibility, as an Molina network provider of health care services, is to:
- Provide medically necessary covered services to members whose care is managed by Molina and comply with all applicable non-discrimination requirements
- Maintain eligibility to participate in Medicare/Medicaid or other federal or state health programs. You may not be excluded from participation while under agreement with Molina
- Comply with all terms of your Participating Agreement. In the event there is a conflict between the terms of your Agreement and the terms of the CCC Plus or Medallion 4.0 contract, the DMAS contract will apply
- Review information submitted to support your credentialing application and correct any errors
- Follow the policies and procedures outlined in the Molina provider manual, any applicable supplements and your provider participation agreement(s) as well as DMAS policies and regulations
- Provide services in accordance with applicable Commonwealth of Virginia and federal laws and licensing and certification bodies. Contracted providers for the CCC Plus or Medallion 4.0 networks are required to abide by DMAS regulations and manuals, and maintain active licensure for their contracted provider type and specialty at each service location
- Provide covered services to Molina members as outlined in the Molina provider manual and applicable supplements and your provider agreement(s), as well as DMAS policies and regulations without exclusion or restriction on the basis of religious or moral objections
- Agree to cooperate and participate with all system of care coordination, quality improvement, outcomes measurement, peer review, and appeal and grievance procedures
- Make sure only providers currently credentialed with Molina render services to Molina members
- Follow Molina's credentialing and re-credentialing policies and procedures
- Participate and collaborate in value-based payment programs and strategies (as agreed upon in your Participating Provider Agreement) that contribute and align with Molina and DMAS care goals and outcomes for members
Molina's responsibilities are to:
- Assist with your administrative questions during normal business hours, Monday through Friday
- Not prohibit, or otherwise restrict healthcare providers acting within the lawful scope of practice, from advising or advocating on behalf of the member who is the provider’s patient, for the member’s health status, medical care, or treatment options, including any alternative treatments that may be self-administered, any information the member may need in order to decide among all relevant treatment options, the risks, benefits, and consequences of treatment or non-treatment. And not prohibit nor restrict the member’s right to participate in decisions regarding his or her healthcare, including the right to refuse treatment, and to express preferences about future treatment decisions
- Ensure health equity in the coverage and provision of services. This includes parity in process and coverage policy between covered medical and behavioral health service needs
- Ensure members’ access to Native American and/or other Indian Health Services (IHS) providers, where available
- Assist providers in understanding and adhering to our policies and procedures, the payer’s applicable policies and procedures, and other requirements including but not limited to those of the National Committee for Quality Assurance (NCQA)
- Maintain a credentialing and recredentialing process to evaluate and select network providers that does not discriminate based on a member’s benefit plan coverage, race, color, creed, religion, gender, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical disability or other status protected by applicable law
- Virginia fraud and abuse
Molina Healthcare seeks to uphold the highest ethical standards for the provision of health care benefits and services to its members and supports the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services.
Definitions:
"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR §455.2) "Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR § 455.2).
Federal False Claims Act, 31 USC Section 3279
The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicaid programs. The act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment.
The term "knowing" is defined to mean that a person with respect to information:
- Has actual knowledge of falsity of information in the claim;
- Acts in deliberate ignorance of the truth or falsity of the information in a claim; or
- Acts in reckless disregard of the truth or falsity of the information in a claim.
The act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.
Deficit Reduction Act
The Deficit Reduction Act (“DRA”) was signed into law in 2006. The law, which became effective on January 1, 2007, aims to cut fraud, waste and abuse from the Medicare and Medicaid programs over the next five years.
Health care entities like Molina, who receive or pay out at least $5 million in Medicaid funds per year, must comply with DRA. As a contractor doing business with Molina, providers and their staff have the same obligation to report any actual or suspected fraud, waste or abuse. Health care entities must have written policies that inform employees, contractors, and agents of the following:
- The Federal False Claims Act and state laws pertaining to submitting false claims;
- How providers will detect and prevent fraud, waste, and abuse;
- Employee protected rights as whistleblowers.
The Federal False Claims Act and the Medicaid False Claims Act have qui tam language commonly referred to as “whistleblower” provisions. These provisions encourage employees (current or former) and others to report instances of fraud, waste or abuse to the government. The government may then proceed to file a lawsuit against the organization/individual accused of violating the False Claims acts. The whistleblower may also file a lawsuit on their own. Cases found in favor of the government will result in the whistleblower receiving a portion of the amount awarded to the government.
The Federal False Claims Act and the Medicaid False Claims Act contain some overlapping language related to personal liability. For instance, the Medicaid False Claims Act has the following triggers:
- Presents or causes to be presented to the state a Medicaid claim for payment where the person receiving the benefit or payment is not authorized or eligible to receive it;
- Knowingly applies for and receives a Medicaid benefit or payment on behalf of another person, except pursuant to a lawful assignment of benefits, and converts that benefit or payment to their own personal use;
- Knowingly makes a false statement or misrepresentation of material fact concerning the conditions or operation of a health care facility in order that the facility may qualify for certification or recertification required by the Medicaid program;
- Knowingly makes a claim under the Medicaid program for a service or product that was not provided.
Whistleblower protections state that employees who have been discharged, demoted, suspended, threatened, harassed or otherwise discriminated against due to their role in furthering a false claim are entitled to all relief necessary to make the employee whole including:
- Employment reinstatement at the same level of seniority
- Two times the amount of back pay plus interest
- Compensation for special damages incurred by the employee as a result of the employer’s inappropriate actions.
Affected entities who fail to comply with the law will be at risk of forfeiting all Medicaid payments until compliance is met. Molina will take steps to monitor Molina contracted providers to ensure compliance with the DRA.
Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from, any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services.
Examples of Fraud and Abuse
By a Member By a Provider - Lending an ID card to someone who is not entitled to it
- Altering the quantity or number of refills on a prescription
- Making false statements to receive medical or pharmacy services
- Using someone else’s insurance card
- Including misleading information on or omitting information from an application for health care coverage or intentionally giving incorrect information to receive benefits
- Pretending to be someone else to receive services
- Falsifying claims
- Billing for services, procedures and/or supplies that have not actually been rendered
- Providing services to patients that are not medically necessary
- Balancing Billing a Medicaid member for Medicaid covered services
- Double billing or improper coding of medical claims
- Intentional misrepresentation of manipulating the benefits payable for services, procedures and or supplies, dates on which services and/or treatments were rendered, medical record of service, condition treated or diagnosed, charges or reimbursement, identity of Provider/Practitioner or the recipient of services, “unbundling” of procedures, non-covered treatments to receive payment, “upcoding”, and billing for services not provided
- Concealing patients misuse of Molina Healthcare card
- Failure to report a patient’s forgery/alteration of a prescription
Other Provider Schemes
- Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients
- A physician knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the physician has a financial relationship (The Stark Law)
- Balance billing—asking the patient to pay the difference between the discounted fees, negotiated fees, and the provider's usual and customary fees
Preventing Fraud and Abuse
Molina and other State and Federal regulatory and law enforcement agencies are working together to help prevent fraud, waste, and abuse. Here are a few helpful prevention tips:
- Do not give your Molina ID card or number to anyone except your doctor, clinic, hospital or other health care provider.
- Do not let anyone borrow your Molina ID card.
- Never lend your social security card to anyone.
- When you get a prescription make sure the number of the pills in the bottle matches the number on the label.
- Never change or add information on a prescription.
- If your Molina ID card is lost or stolen, report it to Molina immediately.
Reporting Fraud, Waste, and Abuse
Molina expects providers and their staff and agents to report any suspected cases of fraud, waste or abuse. Molina will not retaliate against a provider who informs Molina, the federal government, state government or any other regulatory agency with oversight authority of any suspected cases of fraud, waste or abuse.
Molina has the responsibility to assess the merits of any allegation of fraud, waste, or abuse. Molina will coordinate and fully cooperate and assist DMAS and any other state or federal agency in identifying, investigating, sanctioning or prosecuting suspected fraud, abuse or waste. Molina will provide records and information, as requested.
You can report suspected fraud, waste and abuse to Molina by the following methods:
Molina AlertLine: (866) 606-3889
Website: https://molinahealthcare.alertline.comWe accept reports to the Corporate Compliance Hotline 24 hours a day/seven days a week. The hotline is maintained by an outside vendor. Callers may choose to remain anonymous. All calls will be investigated and remain confidential.
In addition to reporting suspected fraud, waste, or abuse to Molina, you can report to these other agencies:
Department of Medical Assistance Services Fraud Hotline
Phone: (800) 371-0824 or (866) 486-1971 or (804) 786-1066Virginia Medicaid Fraud Control Unit (Office of the Attorney General)
Email: MFCU_mail@oag.state.va.us
Fax: (804) 786-3509
Mail: Office of the Attorney General
Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219Virginia Office of the State Inspector General Fraud, Waste, and Abuse Hotline
Phone: (800) 723-1615
Fax: (804) 371-0165
Email: covhotline@osig.virginia.gov
Mail: State FWA Hotline
101 N. 14th Street
The James Monroe Building 7th Floor
Richmond, VA 23219You can also contact the U.S. Department of Health & Human Services Office of Inspector General at:
Office of Inspector General Department of Health & Human Services
Attn: Hotline
P.O. Box 23489
Washington, DC 20026
Phone: 1-800-HHS-TIPS (TTY 1-800-377-4950)
Website: https://oig.hhs.gov/fraud/report-fraud/To report suspected recipient fraud to DMAS, contact:
Department of Medical Assistance Services
Recipient Audit Unit
600 East Broad Street, Suite 1300
Richmond, VA 23219
Phone: (800) 371-0824
Email: Recipientfraud@DMAS.virginia.gov
Website: http://dmasva.dmas.virginia.govFor those who do not have a computer or the internet at home, don’t worry. You can use one at your local public library.
For more information on fraud, waste and abuse, refer to your provider manual.