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Participation Guidelines and Standards of Care

Provider Guidelines:

All Participating Providers are expected to:

• Perform duties in their area of specialty.
• Provide preventive care services, including well child, adolescent, and adult preventive services (e.g., pap smears, HIV counseling, immunizations). Provide complete current information concerning a diagnosis, treatment, treatment options and prognosis from a physician or other Provider in terms the patient can be reasonably expected to understand. When it is not advisable to give such information to the patient, the information will be made available to an appropriate person on the patient’s behalf.
• Provide information from a physician or other Provider necessary to give informed consent prior to the start of any procedure or treatment. Afford the patient the opportunity to refuse treatment to the extent permitted by law and to be informed of the medical consequences of that action.
• Be responsible for the supervision of patient care if a mid-level practitioner or resident renders care.
• Be responsible for patient care twenty-four hours a day or make arrangements with an alternate Participating Provider who must be available by telephone and can be available for coverage. If you use an answering machine, the message must direct the Member to a live voice.
• Promptly report to the referring primary care physician with any significant findings or urgent changes in therapy resulting from the consultation.
• Work closely with the Molina Quality and Healthcare Services Departments to assure patient compliance with follow-up.
• Comply with Molina’s credentialing criteria and policies.
• Primary Care Providers (PCP) will coordinate care when the patient is referred to a specialist.
• Comply with Molina’s procedures on referrals and preauthorization.
• Refer patients to the Molina Healthcare Services Department who require Case Management Services.
• Maintain confidentiality of medical information. For patients who have AIDS or who have been tested for the HIV virus, please see NYS Public Health Law Article 27.F, Section 2782.
• Comply with New York State Department of Health Communicable Disease Reporting Requirements (e.g. HIV, Tuberculosis, Hepatitis C etc.). These requirements are found at http://www.health.ny.gov/professionals/diseases/reporting/communicable
• Communicate with patients regarding areas of needs, and concerns requiring immediate attention.
• Comply with Federal and state requirements for informed consent for hysterectomies and sterilization. Requirements are found on http://www.health.state.ny.us.
• Utilize formal Mental Health and Substance Use Assessment Tools.
• Adhere to the Molina Pharmacy Formulary. See our website for detailed information.
• Refer patients needing urgent evaluation or emergency care to a Participating emergency department or urgent care site whenever possible.
• Adhere to Molina’s Appointment Access & Availability Guidelines. Ensure that Members with appointments are not routinely made to wait longer than one (1) hour.
• Adhere to Child/Teen Health Guidelines.
• Comply with the Adult Preventive Care Guidelines.
• For Medicaid/FHP provide behavioral health screening for all Members, as appropriate
• Make available records and medical information for Quality Improvement/Utilization Review activities.
• Follow Molina’s standards for Medical Records.
• Receive signed acknowledgment from the Member prior to rendering non-covered services. Signed acknowledgments confirm the Member’s knowledge of non-covered services under their Benefit Plan.
• Participate in Molina Health Advisory Committees if possible.
• Treat all patients equally;
• Not discriminate because of race, sex, marital status, sexual orientation, religion, ancestry, national origin, place of residence, disability, source of payment, utilization of medical, mental health services or supplies, health status, or status as a Medicare or Medicaid recipient, or other unlawful basis; and,
• Agree to observe, protect, and promote the rights of Molina’s Members as patients.

For your reference, we have included the Molina’s Member Rights and Responsibilities as a Section in this Provider Manual.

In becoming a Molina Provider, you and your staff agree to follow and comply with Molina’s administrative, medical management, quality assurance, and reimbursement policies and procedures.

Nondiscrimination of Health care Service Delivery

Molina complies with the guidance set forth in the final rule for Section 1557 of the Affordable Care Act, which includes notification of nondiscrimination and instructions for accessing language services in all significant Member materials, physical locations that serve our Members, and all Molina Healthcare of New York website home pages. All Providers who join the Molina Provider network must also comply with the provisions and guidance set forth by the Department of Health and Human Services (HHS) and the Office for Civil Rights (OCR). Molina requires Providers to deliver services to Molina Members without regard to race, color, national origin, age, disability or sex. This includes gender identity, pregnancy and sex stereotyping. Providers must post a non-discrimination notification in a conspicuous location of their office along with translated non-English taglines in the top fifteen (15) languages spoken in the state to ensure Molina Members understand their rights, how to access language services, and the process to file a complaint if they believe discrimination has occurred.

Additionally, Participating Providers or contracted medical groups/IPAs may not limit their practices because of a Member’s medical (physical or mental) condition or the expectation for the need of frequent or high cost-care. Providers must not discriminate against Members based on their payment status and cannot refuse to serve Members because they receive assistance with Medicare cost sharing from a State Medicaid Program.

Additional information regarding Provider Responsibilities can be found in the Provider Manual.