Examples of Molina Healthcare in a sentence
Molina Healthcare reserves the right to require that additional documentation be made available as part of its coverage determination; quality improvement; and fraud; waste and abuse prevention processes.
Molina Healthcare may deny reimbursement or take additional appropriate action if the documentation provided does not support the initial determination that the drugs or services were medically necessary, not investigational or experimental, and otherwise within the scope of benefits afforded to the member, and/or the documentation demonstrates a pattern of billing or other practice that is inappropriate or excessive.
If a member enrolls in Molina Healthcare with an effective enrollment date of either November 1 or December 1, the transition policy will extend across the contract year for transition supplies of medication.
The purpose of the Policy and Procedure is to ensure necessary continuity of treatment and to provide adequate time and transition process to introduce the enrollee and their prescribing physician to the Molina Healthcare Formulary.
Molina Healthcare, like others in our industry, must comply with these laws and proactively ensure that government funds are used appropriately.
If the LTC (and its preferred pharmacy) are not part of the network, either by choice or by not meeting conditions of participation, Molina Healthcare will pay for the same medication supply at LTC pharmacy network rates.
Molina Healthcare will make arrangements to continue to provide necessary Part D drugs to enrollees and non-Part D drugs, as required by Medicaid, to MMP enrollees via an extension of the transition period, on a case-by-case basis, to the extent that their exception requests or appeals have not been processed by the end of the minimum transition period and until such time as a transition has been made (either through a switch to an appropriate formulary drug or a decision on an exception request).
For non-LIS eligible enrollees, Molina Healthcare will ensure that the co-pay or cost-sharing for a temporary supply of drugs provided under its transition process is based on one of its approved cost-sharing tiers and is consistent with co-pays or cost-sharing Molina Healthcare would charge for formulary drugs subject to utilization management edits provided during the transition that would apply once the utilization management criteria are met.
For current enrollees whose drugs are no longer on the Molina Healthcare formulary, Molina Healthcare will ensure a meaningful transition by either: (1) providing transition supplies of medications the same as the transition supplies required for new enrollees at the beginning of a new contract year; or (2) activating a transition process prior to the beginning of a new contract year.
Molina Healthcare does not specifically reward practitioners or other individuals for issuing denials of coverage or care.