Molina Healthcare Credentialing Services for your Independent Practice

Our aim at Molina Healthcare is to deliver quality healthcare services to financially challenged families and people who are eligible for government programme. The Corporate Credentialing Department is responsible for credentialing both individual healthcare practitioners (e.g., doctors) and institutions (e.g., hospitals) in each of Molina’s 10 states of service. Here’s how we used Laser fiche to transform a paper-intensive procedure into a paperless one.

The Credentialing Process

Aim of providing services in the Molina network, a providers (practitioner or facility) must go through the credentialing process, which analyses and confirms a provider’s credentials and history to verify that the provider can safely treat users list. For the provider to continue in the network, this process must be done every three years.

To completing each provider’s dossier, our Corporate Credentialing Division collaborates with three other offices.

The Contracting Team: which is in charge of starting the contracting procedure and acquiring a credentialing request.
The Provider Services department: Which is in charge of gathering information from unresponsive contracted suppliers.
The Provider’s Actual Office: which is in charge of giving explanation and missing information.

The credentialing procedure used to be extremely time-consuming and inefficient because files had to be shared between departments numerous times—and often shipped back and forth across states. We used Laser fiche Workflow to streamline the process.

Because a provider must be credentialed separately from each state, each state has its own Laser fiche repository. Each of these sources has a folder structure that corresponds to the various steps in the procedure, which we were able to reproduce. As the application progresses through the credentialing process, it is routed to a separate folder and person, perhaps in a different physical location.

Depending on the specific scenario, the application can take one of numerous paths (e.g., one application will move through for regular approval, while another might be discontinued mid-process).

We no longer have to mail massive boxes of credentialing applications across the country. Instead, we simply transmit files with a few mouse clicks in a matter of seconds.

Initiation of an application.

• The Council for Affordable Quality Healthcare (CAQH) database accounts for over 60% of all applicants. A provider submits a single application to CAQH, which can then be used to apply to various health insurance companies in different states.

• We use Laser fiche Snapshot and locally developed software to batch import such programme into Laser fiche after downloading them from CAQH.

• When feasible, we also use the XML form of the data to upload straight into our credentialing system.

• Approximately 40% of submissions are still written by hand.

• These requests must be digitized into Laser fiche and the data manually entered into our credential system.

Processing

• During this stage, we ensure that the applications are comprehensive and, if necessary, request further information.

• We also validate numerous credentials (e.g., medical license, board certification, etc.) and import them into the credentials file using Laser fiche Snapshot.

• If the source does not answer to our demands for missing or contradictory information after three attempts, the application is terminated, and our networks divisions (Contracting or Provider Services) may elect to pursue the information.

Quality Review

When the application is finished, it must go through a quality assurance process. To highlight the amount of detail used here, the following are some of the primary things that must be validated for quality:

• Licenses.

• Education and training are essential.

• Certifications from the Board of Directors.

• Sanctions from the federal government

• Work experience.

• Insurance against malpractice.

• History of malpractice.

At any time during the quality assessment process, further information may be discovered that must be sought, or the application may be terminated.

Final Decision

During this step, provider files are assessed for a final judgement by a peer review committee (for files with concerns) or a medical director (for clean files).

Providers are then notified as to whether their application was approved, refused, or cancelled.

If the application was withdrawn, the provider might resubmit her application with the missing information. It will then have to go through the full procedure once more. If a provider’s contract was terminated due to a failure to submit the required missing documentation, the provider must restart the contracting procedure and be treated as an original credentialing applicant.

We retain the records.

Once the application has been approved and reviewed, it is moved to the “Provider Storage” folder in the Laser fiche repository, where it will be kept for up to 40 years after the contract has been terminated, depending on the retention laws in each state.

Efficiencies gained

Implementing paperless credentialing helped us to:

• Decrease our average processing time per file from 53 days to 35 days.

• Decrease our cost per file from $180 to $108, saving us a total of $750,000 in the first year.

• Increase our average quality scores from 83% to 92%.

• Improve the speed of credentialing in new states that we service.

• Increase the general volume capacity when application volume fluctuates.

• Improve our confidence in retrieval of documentation for audits.

Molina Healthcare Credentialing Phone number

Molina Healthcare provides a dedicated phone number to assist you with all of your LTSS requirements. If you have any questions concerning LTSS services, please contact us at (855) 687-7860, Monday through Friday, 7:00 a.m. – 7:00 p.m.

Molina Healthcare Enrollment Applications

Follow the instructions and submit the Enrollment Form as soon as possible.

Before submitting an Individual Enrollment Request form, we recommend that you read the Summary of Benefits.If you need assistance completing this enrollment form or have concerns about plan benefits prior to enrollment, please contact us at (866) 403-8293, TTY/TDD: 711, Monday through Saturday, 8:00 a.m. to 8:00 p.m. local time. Molina Based on Medicare enrollment rules, Medicare determines when your Enrollment Form is considered complete. The Centers for Medicare & Medicaid Services must approve the enrollment (CMS). If CMS does not accept your enrollment, we will contact you promptly.

Molina Healthcare Email Address

Contact us at that email address EDI.ERAEFT@MolinaHealthcare.com. We’ll solve all issues at prompt manner.