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As a participating provider with Molina Healthcare, 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 Healthcare 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.

Molina Healthcare pays clean claims submitted for covered services provided to eligible members. In most cases, we pay clean claims within 30 days.

*IMPORTANT INFORMATION TO ENSURE CLAIM ACCEPTANCE*

The State of Nebraska’s Department of Health and Human Services (NE DHHS) assigns a Provider Medicaid ID number to each Provider address. The Provider Medicaid ID number/address/NPI combination along with the Group NPI and Tax ID on file with Molina, must match the information that is on file with NE DHHS for claim payment; therefore, all changes should be made through the NE DHHS website. Discrepancies in information can impact claims payment and result in claim rejection. To prevent issues, please follow these steps:

1. Visit our Provider Online Directory to validate your information with Molina is the same as your information on file with NE DHHS.
2. Corrections, add/changes to Group affiliations or locations, or updates to Tax ID, etc. must be completed on the NE DHHS Provider Data Management System (Maximus) and will be sent to Molina. Please visit the NE DHHS Provider Data website to make changes.

How do I submit my claims to Molina Healthcare?

We recommend that you submit claims through the Electronic Data Interchange (EDI) for efficient processing and payment. We work with SSI Claimsnet for all EDI transactions.

When submitting your 837 (I & P) files, please use our Payer ID: MLNNE

Learn more about EDI

Submitting electronic claims

Molina Healthcare offers a direct submit/web-based claims option through Availity. 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 as one of your payers. If you are not currently registered with Availity please visit www.availity.com to get connected.

Submitting paper claims:

To submit paper claims, please mail to:

Molina Healthcare of Nebraska, Inc
PO Box 93218
Long Beach, CA 90809-9994

If you have question, contact the claims department at (844) 782-2678.

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 Healthcare provider manual.

Except for claims from pharmacy providers, Molina will ensure that all provider claims are processed according to the following timeframes:

• Within five (5) business days of receipt of a claim, Molina will provide an initial screening and either reject the claim or assign a unique control number and enter it into the system for processing and adjudication.
• In accordance with 42 CFR § 447.45, Molina will adjudicate a minimum of ninety percent (90%) of all claims for services billed to Molina within fifteen (15) business days of the date of receipt. The date of receipt is the date Molina receives the claim.
• In accordance with 42 CFR § 447.45, Molina will adjudicate a minimum of ninety-nine (99%) of all claims for services billed to Molina within sixty (60) calendar days of the date of receipt.
• Molina will fully adjudicate (pay or deny) all other claims within six (6) months of the date of receipt.

For pharmacy providers, in accordance with 42 CFR § 447.45, Molina will establish, at a minimum, a weekly payment cycle so that a minimum of 90% of all claims from pharmacy providers for covered services are adjudicated within seven (7) calendar days of receipt and ninety-nine (99%) of all claims are adjudicated within fourteen (14) calendar days of receipt, except to the extent providers have agreed to an alternative payment schedule set forth in the provider contract.

A Provider Claims Inquiry is a provider’s initial request to adjust a claim that is not related to a clinical decision. Provider Claims Inquiries are accepted by phone within 90 days from the date on the Explanation of Payment (EOP) or the Provider Remittance Advice (PRA).

To request a Provider Claims Inquiry, please call our Provider Services Contact Center at 1-844-782-2678.

If you would like to (1) request adjustment of a claim that is related to a clinical decision, or (2) submit a formal request to adjust a claim, or (3) if you are dissatisfied with the outcome of your claim processing or initial claim adjustment, please use Molina’s Provider Appeals Process found in section “Provider Appeal Process and Timeline”.

A Provider complaint that is related to a Claim, such as processing, payment, or non-payment of a Claim, is considered a Provider Appeal. Provider appeals are requests to investigate the outcome of a finalized Claim.

Provider Appeals are accepted electronically and in writing within 90 days from the date on the Explanation of Payment (EOP) or the Provider Remittance Advice (PRA). Molina will acknowledge Provider Appeals within three (3) business days from receipt. Molina will address each Provider Appeal, resolve, and provide written notice within 30 calendar days. Molina will adjudicate each appealed claim to a paid or denied status within thirty (30) business days of receiving notice of a resolution.

Providers are encouraged to submit Provider Appeals electronically, using the Availity Essentials portal. Alternatively, Provider Appeals may be submitted using the form located on the MolinaHealthcare.com website. You can find the form here.

The item(s) being submitted should be clearly marked as a Provider Appeal and must include the following documentation:

• The Molina Provider Appeal Form
• Any documentation to support the adjustment of the claim and a copy of the authorization form (if applicable) must accompany the appeal request.
• The Claim number clearly marked on all supporting documents.

Provider Appeals shall be submitted at:

• Availity Essentials portal: Provider.MolinaHealthcare.com
• Fax:     (833) 832-1517
• Mail:     Molina Healthcare of Nebraska, Inc

              Appeals & Grievances Unit         
              PO Box 182273 
              Chattanooga, TN 37422

Provider may file appeals and/or grievances on behalf of a Molina Healthcare member with the member’s written consent. Providers should use Molina’s Member Appeal/Grievance Form if they want to file an appeal or grievance on behalf of a member. You can find the form here.

To file a member appeal or grievance:

• Phone: (844) 782-2018
• Fax: (833) 635-2044
• Mail:  Molina Healthcare of Nebraska, Inc;
             Appeals & Grievances Unit 
           PO Box 182273 
           Chattanooga, TN 37422

We will make our appeal decision and send to you in writing within 30 days of receipt of the request. Expedited appeals will be resolved within 72 hours.

A grievance on behalf of a Molina Healthcare member can be filed any time. We resolve routine complaints immediately. We will notify the member and/or the representative of the resolution to their grievance within 90 days of the grievance filing.