Claim Editing Process

Molina Healthcare has a claims pre-payment auditing process that identifies frequent correct coding billing errors such as:

  • Bundling and unbundling coding errors
  • Duplicate claims
  • Services included in global care
  • Incorrect coding of services rendered

Coding edits are based on Current Procedural Terminology (CPT), Medicaid Purchasing Administration (MPA) guidelines, industry standard National Correct Code Initiative (NCCI) policy and guidelines, and industry payment rules and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB). If you disagree with an edit please follow the Denied Claim Review Request guidelines located in Section 11 of the Provider Manual.

Code Edit Policy Reconsiderations

A provider can request a reconsideration regarding a code edit policy in situations where the provider's and Molina Healthcare's correct coding policy sources conflict, or where they may have different interpretations of a common correct coding policy source. The Provider will be notified of Molina Healthcare's decision in writing within 60 calendar days of the receipt of the Code Edit Reconsideration request, unless additional supporting documentation is required.

All requests for Code Edit Policy Reconsiderations must be submitted to Molina Healthcare in writing and should include the following:

Explanation of why the provider does not agree with Molina Healthcare's current correct coding policy or interpretation. Include the supporting alternative policy information and the source where it can be found.

  • Must clearly indicate "Code Edit Policy Reconsideration Request"
  • Contact information for your organizations point person, i.e. name, contact number, e-mail address >
  • Relevant CPT/HCPCS codes or code combination examples
  • Specific claim examples of denied services related to the code edit
  • Must be addressed to the attention of Molina Healthcare's Provider Services Department

Code Edit Policy Reconsiderations do not apply to eligibility limitations, non-FDA approved services, medical policies, benefit determinations or contractual disputes. Code Edit Reconsiderations should be mailed to:

Provider Services Department
PO Box 4004
Bothell, WA 98041-4004‚Äč