Molina Healthcare Inc · NYSE:MOH
Molina Healthcare — Investor Presentation (June 2025)
29 slides from Molina Healthcare's investor presentation, Jun 30, 2025
Slide 1: Billing Guidelines
Billing Guidelines Provider Engagement Team Training
Slide 2: Topics
Topics Prior Auth Look-up Tool & How to 1 Billing Guidelines 5 Request a Prior-Auth 2 Encounter Data 3 Appeals and Grievances 4 Taxonomy and Medicaid ID
Slide 3: Important
Important • Molina Medicaid and Marketplace claims must be submitted by to Molina within six (6) months after the discharge for inpatient services or the date of service for outpatient services. When Molina is secondary, claims, whether paper or electronic, must be submitted within 90 days from the
Slide 4: Billing Guidelines
Billing Guidelines • How to submit a claim • Timely Filing • Balance Billing • Claim Resubmissions/Corrected Claims
Slide 5: Claim Submission
Claim Submission Providers may submit claims to Molina electronically or on paper. Availity Portal (preferred): Provider.MolinaHealthcare.com Marketplace/Medicaid/LTC Claims Submission Address Molina Healthcare of Florida P.O. Box 22812 Long Beach, CA 90801 EDI Claims Submission (All LOBs) SSI Group
Slide 6: Before a claim is filed to Molina Healthcare, consider reviewing the following
Before a claim is filed to Molina Healthcare, consider reviewing the following: • Member eligibility and ID# • Claim’s timely filing • Primary versus secondary insurance • Patient liability has been confirmed through DCF documentation or the DCF website • Rendered services are covered • Rendered ser
Slide 7: Before a claim is filed to Molina Healthcare, consider reviewing the following
Before a claim is filed to Molina Healthcare, consider reviewing the following: Whether paper or electronic, the following information must be included on every Claim: • Member name, date of birth and Molina Member ID number • Member’s gender • Member’s address • Date(s) of service • Valid Internati
Slide 8: Before a claim is filed to Molina Healthcare, consider reviewing the following
Before a claim is filed to Molina Healthcare, consider reviewing the following: Services are not reimbursed when any of the following apply: • Services does not meet medical necessity criteria • Authorization was not obtained for a service requiring prior authorization • Member is not active at the
Slide 9: Before a claim is filed to Molina Healthcare, consider reviewing the following
Before a claim is filed to Molina Healthcare, consider reviewing the following: • Days or units, as applicable • Provider tax identification number (TIN) • 10-digit National Provider Identifier (NPI) • Rendering Provider name as applicable • Billing/Pay-to Provider name and billing address • Billing
Slide 10: Balance Billing
Balance Billing 10 Participating providers shall accept Molina Healthcare’s payments as payment in full for covered services. Providers may not balance bill the Member for any covered benefit, except for applicable copayments, coinsurance, and deductibles, if any. Your office is responsible for veri
Slide 11: Claim Resubmissions/Corrected Claims
EDI (Clearinghouse) Submissions for Corrected Claims Claim Resubmissions/Corrected Claims Corrected Claim information submitted via EDI submission are required to follow Providers may correct any necessary field of the CMS-1500 and CMS-1450 electronic Claim standardized Accredited Standards Committe
Slide 12: Billing Forms
Billing Forms • CMS 1500 • UB04
Slide 13: CMS 1500 form
CMS 1500 form Professional Paper Claim Form Sample Link: cms1500.pdf
Slide 14: UB-04 form
UB-04 form Institutional Paper Claim Form Sample Link: ub-40-P.pdf (cdc.gov) Instructions: App L - UB04 Form Instructions.xls (myflorida.com)
Slide 15: Encounter Data
Encounter Data ee O c] LINA’ ag You Matter ry) | MOLINA 639 to Molina
Slide 16: Encounter Claims
Encounter Claims Each capitated provider/organization delegated for claims processing is required to submit Encounter data to Molina for all adjudicated claims. Encounter data must be submitted at least once per month, and no later than seven (7) days following the date on which Molina adjudicates t
Slide 17: Provider Appeals and Grievances
Provider Appeals and Grievances
Slide 18: Provider disputes and timely resolution of complaints
Molina Healthcare is committed to the timely resolution of all provider complaints. Provider disputes are typically disputes related to overpayment, underpayments, untimely filing, and bundling issues. Any disagreement regarding the processing, payment or non-payment of a claim is considered a Provi
Slide 19: Provider Tip Sheet
Provider tip sheet with the above information is available here: Provider Tip Sheet
Slide 20: Taxonomy/NPI
Taxonomy/NPI ee O C) MOLINA: A You Matter BRR MOLINA 639 to Molina
Slide 21: Taxonomy and NPI match
Taxonomy and NPI match As stated in the communication to providers dated February 6, 2023, all claims submitted to Molina must include an appropriate taxonomy code in order to avoid claim denial. Effective May 1, 2023, any claims with taxonomy information that doesn’t match your provider enrollment
Slide 22: Authorization lookup tool
Authorization lookup tool ee O O) MOLINA: ag You Matter BRR MOLINA 639 to Molina
Slide 23: Prior-Auth look up tool
Prior-Auth look up tool Florida Providers Home (molinahealthcare.com)
Slide 24: How to Request Prior-Auth
How to Request Prior-Auth Prior authorization requirements are designed to assure the medical necessity of service, prevent unanticipated denials of coverage, ensure participating Providers are utilized and ensure that all services are provided at the appropriate level of care for the Member’s needs
Slide 25: Requesting Prior Authorizations
Requesting Prior Authorizations
Slide 26: Prior Auth Requests
Prior Auth Requests Send requests for prior authorizations to the Utilization Management Department using the Molina Healthcare of Florida Prior Authorization Guide and Service Request Form included in your Welcome Kit and also available on our website, at: Medicaid: MolinaHealthcare.com/Providers/F
Slide 27: Modes of Submission
Modes of Submission Online (preferred): Providers should register on the Availity Portal at Provider.MolinaHealthcare.com to avoid any disruption in accessibility and functionality. Mail: Molina Healthcare of Florida, Inc. Healthcare Services Authorizations & Inpatient Census 8300 NW 33rd Street, Su
Slide 28: Pharmacy Prior-Auth
Pharmacy Prior-Auth Some medications, such as those listed with (SP) Specialty on the Preferred Formulary require clinical notes for review. If clinical information and/or medical justification is missing, Molina will either fax or call your office to request that the clinical information be sent fo
Slide 29: Contact your provider services manager
If you have further questions, contact your provider services manager or e-mail [email protected] Access contact information for our Provider Services Managers by Regions: Contact Us
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