Provider Bulletins
- DOH LTSS Process (7/15/2022)
- Superior Vision - Molina Provider Notice (11/21/2021)
- PT, OT, ST Coding Changes (9/10/2020)
- Pharmacy Carve Out Member Letter
- Monroe Plan/Molina Fact Sheet
- Thrive at Home “Gap Closure” Program
- IMPORTANT REMINDER: Cultural Competence Training for Participating Providers Due Oct 1st, 2022
- Changes to Prior Authorization Requirements and Billing Codes Available to Bill
- Changes to Molina Healthcare Home Care Prior Authorization Requirements
- Professional Office Lab Billing and Reimbursement Update When Using Modifiers
- Community Laboratory Fee Schedule Effective January 1, 2023
- New York State Benefit Changes Effective 1/1/2023 for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Essential Plan (EP), and Child Health Plus (CHP) Products
- Molina Availity Essentials Provider Portal
- Access and Availability Reminder
- Pharmacy Benefits Transitioning from Medicaid Managed Care Plan to NYRx, the Medicaid Pharmacy Program
- Provider Annual Attestations
- Help Your Patients Keep Their Health Insurance
If providers would like their patients to continue PCA/CDPAS services, updated MD orders must be faxed to Molina UM (866-879-4742) at least 30 days prior to authorization ending. The form (DOH 4359) must be completed in FULL. A missing CIN or DOB nullifies the form; incomplete forms are considered unacceptable as per NYS DOH Regs. Noncompliant orders will lead to your patient losing their aide services and it can take about 4-6 weeks for services to restart. Please review the forms for completeness before faxing to Molina.
Did you know that every Molina member receiving these services has an assigned RN Case Manager who speaks to the member every month? Please contact the Monroe Plan triage line at 844-337-7144 to get connected to the assigned Case Manager. S/he can assist you by providing support in submitting the 4359, answering questions regarding the LTSS process or address any concerns about your patient receiving these services.
To access the Physician Order Form, click here: Physician’s Order for Personal Care/Consumer Directed Personal Assistance Services (ny.gov)
Respectfully,
Monroe Plan for Medical Care Provider Network
Effective November 1, 2021, Molina Healthcare of NY (“Molina”) will be using a new vendor to manage its vision benefit for members enrolled in its Medicaid Managed Care, Essential Plan, HARP, and Child Health Plus products. The name of the new vendor is Superior Vision.
Click here to download: Superior Vision – Molina Provider Notice 11/2021
Please download the Coding crosswalk for claims submission for guidance
relates to PT, OT and ST services rendered to Molina Health Plan members.
Click here to download: Pharmacy Carve Out Member Letter Notice
You can also access this notice at: health.ny.gov
Effective July 1, 2020, YourCare Health Plan’s Medicaid Managed Care, HARP, Essential Plan, and Child
Health Plus transitioned to Molina Healthcare of New York, Inc. Concurrently, Monroe Plan for Medical Care and affiliated entities entered into an agreement with Molina to provide network management and care management services.
Monroe Plan Introduces Thrive at Home “Gap Closure” Program
Our Thrive at Home offers a no cost, additional clinical resource to our IPA providers.
Our Thrive at Home Outreach and Clinical Team will schedule and perform preventative testing and follow up right in the patients home which makes all the difference in reaching difficult-to-engage Medicaid and HARP patients.
We know that Medicaid and HARP patients often face significant obstacles to getting to the care they need such as limited transportation, childcare, and economic means. We also know that limited practice resources and time can impact quality of care. The in-home services provided through Thrive at Home can augment your team AND help patients overcome obstacles to accessing care. Most importantly, this program can serve as a gateway to reconnecting the patient with their primary and specialist caregivers! Click here to learn more.
Mainstream Medicaid Managed Care Providers are required to ensure the cultural competence of practice staff and to certify annual completion of New York State approved cultural competence training curriculum. The approved training, titled Think Cultural Health, offers several provider specific programs online, at no cost: https://thinkculturalhealth.hhs.gov/education. Providers and appropriate staff should/should have complete(d) this training by October 1st, 2022, and annually thereafter. If you have not shared your certificate of completion, please forward your certificate of completion to: providerrelations@monroeplan.com.
As Always,
Monroe Plan for Medical Care Provider Network Management
TO: Participating Monroe Plan IPA and YourCare IPA Network PT-OT-ST Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: November 15, 2022
SUBJECT: Changes to Prior Authorization Requirements and Billing Codes Available to Bill
Effective November 1, 2022 please find below additional codes and/or prior authorization requirements that will apply to certain therapy services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.
Please note that prior authorization will be required after 12 visits for Physical, Occupational, and Speech Therapy services for the codes listed below. Reimbursement will be made based on your Monroe Plan IPA or Your Care IPA contracted rates and community fee schedules.
The CPT codes referenced above are:
92507 TX SPEECH LANG VOICE COMMJ AND AUDITORY PROC IND
92508 TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2 OR GRT INDIV
97110 THERAPEUTIC PX 1 OR GRT AREAS EACH 15 MIN EXERCISES
97112 THER PX 1 OR GT AREAS EACH 15 MIN NEUROMUSC REEDUCA
97129 THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES
97130 THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES
97530 THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN
97542 WHEELCHAIR MGMT EA 15 MIN
The Codification Matrix on the Molina Healthcare website has also been updated and posted with the above referenced changes. In addition, this notification will be posted to the Monroe Plan website for future reference.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information. You may also contact Molina Healthcare’s Utilization Management Department at 1-877-872-4716 regarding the new prior authorization requirements.
Thank you for all you do for our members and our communities at large.
TO: Participating Monroe Plan IPA and YourCare IPA Network Home Care Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: November 15, 2022
SUBJECT: Changes to Molina Healthcare Home Care Prior Authorization Requirements
Please find below changes in prior authorization requirements for certain procedure codes that will apply to home care services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.
Effective November 1, 2022, prior authorization will be required for home health care services rendered after the first six (6) visits for the following CPT codes:
• S9123 – RN Per Hour
• T1030 – RN Per Diem
• T1031 – LPN Per Diem
• S9131 – PT, Per Diem
• S9128 – ST, Per Diem
• S9129 – OT, Per Diem
• S9122 – HHA, hourly
The Codification Matrix on the Molina Healthcare website has also been updated and posted with the above referenced changes. In addition, this notification will be posted to the Monroe Plan website for future reference.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information. You may also contact Molina Healthcare’s Utilization Management Department at 1-877-872-4716 regarding the new prior authorization requirements.
Thank you for all you do for our members and our communities at large.
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: November 15, 2022
SUBJECT: Professional Office Lab Billing and Reimbursement Update When Using Modifiers
This notice is to provide guidance and clarification when billing lab codes using a CPT code and related modifiers for laboratory services provided in a professional office setting. This change will be effective January 1, 2023 and is applicable to any lab services rendered to Molina Healthcare Medicaid Managed Care, HARP, Essential Plan, and Child Health Plus members.
The intent of this change is to mirror NYS Medicaid billing guidelines and provide clarification as to payment rates when modifiers are used by your office for lab services.
Modifier 26 / Professional Component: Lab procedures are a combination of a physician component and a technical component. When the professional component, only, is performed and reported separately, the service may be identified by adding the modifier “26” to the procedure number. Reimbursement will then equate to 40% of the maximum global Community Lab Fee Schedule amount.
Modifier TC / Technical Component: When the technical component, only, is performed and reported separately, the service may be identified by adding the modifier “TC” to the procedure number. Reimbursement will then equate to 60% of the maximum global Community Lab Fee Schedule amount.
If no modifier is included with the laboratory code billed, then the full global fee as reflected in the community-based fee schedule will be reimbursed.
The Monroe Plan and YourCare IPA community-based laboratory fee schedule effective January 1, 2023, which is equivalent to 100% of the prevailing New York State Medicaid Lab fee schedule, will be posted to the Monroe Plan website (www.monroeplan.com) under the IPA and Provider Services tab.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.
Monroe-Plan-YourCare-IPA-Laboratory_Fee_Schedule-Effective-Jan-01-2023
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: December 1, 2022
SUBJECT: New York State Benefit Changes Effective 1/1/2023 for Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Essential Plan (EP), and Child Health Plus (CHP) Products
In accordance with New York State requirements, this notice is to provide updated member benefit information effective January 1, 2023, regarding the products referenced above as administered by Molina Healthcare of New York Inc.
Please note that some benefits may have limitations and if there are questions as to whether a service is covered or requires Prior Authorization, please reference the Prior Authorization tools located on the Molina website.
For additional information and a chart summary of the specific added benefits and services, please refer to the
attachment to this notice as well as visiting Molina’s website link below at:
https://www.molinahealthcare.com/providers/ny/medicaid/comm/bulletin.aspx
This notice and the updated grid will also be posted to the Monroe Plan website at (www.monroeplan.com) under the IPA and Provider Services tab.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.
Click here to review benefit changes.
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: February 8, 2023
SUBJECT: Molina Availity Essentials Provider Portal
Beginning March 28, 2023, Availity Essentials will be the official secure provider portal for Molina Healthcare providers. Molina’s legacy portal will no longer be available for direct transactions. Please register on Availity to ensure that you have uninterrupted access to all your portal information, tools, and functions.
To register visit: https://www.availity.com/molinahealthcare
This notice and the updated grid will also be posted to the Monroe Plan website at (www.monroeplan.com) under the IPA and Provider Services tab.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.
Provider Bulletin
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: March 1, 2023
SUBJECT: Access and Availability Standards
In accordance with New York State requirements, this notice is to serve as a reminder that New York State routinely completes surveillance activities to evaluate compliance with the following appointment availability standards, (Medicaid Model Contract 15.2, Appointment Availability Standards). By following the appointment availability standards established by the New York State Department of Health we can improve patient access to routine, urgent, preventive and specialty care. We also follow 24-hour access standards to measure after-hours access.
These standards apply to all lines of business, to learn more view our tip sheet: Access-and-Availability-Standards_MPwebsite_TIPS_2022.pdf (monroeplan.com)
This notice and the tip sheet will also be posted to the Monroe Plan website at (www.monroeplan.com) under the IPA and Provider Services tab.
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.
PROVIDER BULLETIN
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: 03/23/2023
SUBJECT: Pharmacy Benefits Transitioning from Medicaid Managed Care Plan to NYRx, the Medicaid Pharmacy Program
Effective April 1, 2023, New York State Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) Plans, Health and Recovery Plans (HARPs), and HIV-Special Needs Plans (SNPs) will have their pharmacy benefits transitioned from their Medicaid Managed Care Plan to NYRx, the Medicaid Pharmacy Program. Click the link below for information regarding the Pharmacy Benefit Transition in the October 2022 Special Edition Medicaid Update New York State Medicaid Update:October 2022 NYRx Pharmacy Benefit Transition.
Questions and Additional Information:
Guidance for Providers NOT Enrolled in Medicaid:
- Providers may check their enrollment status by reviewing the Medicaid Pended Provider Listing found here: Provider Verification
- Prescribers that are not enrolled in the Fee-For-Service program must enroll, to continue serving Medicaid Managed Care members. Instructions for checking enrollment status and enrollment tips can be found on the eMedNY Provider Enrollment
- Questions regarding the enrollment process, your enrollment status, or what you need to do to enroll, please contact providerenrollment@health.ny.gov or call the eMedNY Call Center at 1-800-343-9000
- Enrollment policy questions should be directed to the Medicaid Pharmacy Policy
Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
Guidance for Navigating the New NYRx Pharmacy Program:
- NY Medicaid Pharmacy Program Information for Prescribers: Prior Authorization Information
- NYS NYRx Quick Reference Guide: NYS NYRx FAQ
- Member Fact Sheet: What Members Need to Know Handout
As always, please do not hesitate to contact us directly at our general Provider Relations e-mail address providerrelations@monroeplan.com with any questions pertaining to this information.
Thank you for all you do for our members and our communities at large.
Provider Relations & Network Management
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: 04/03/2023
SUBJECT: Provider Annual Attestations
ATTESTATION FORMS DUE MAY 1
Each year, Medicaid managed care providers are required to complete three brief attestation forms – DO, Employee, HIV forms. These forms are a NYS Medicaid Requirement. Below is a brief description of what each form will confirm. The forms are available through the Monroe Plan Provider Portal or our Monroe Plan website. If you have not already registered for the Monroe Plan Provider Portal, you can access the portal by clicking here: Monroe Plan Provider Portal or by visiting our website: Provider Resources & Forms – Monroe Plan for Medical Care. All forms should be sent to providerrelations@monroeplan.com.
If you have standard version of these forms already completed, you can submit those completed forms to providerrelations@monroeplan.com and that will satisfy this requirement.
Below is a list of attestation forms needed and a brief description of each form.
- Provider Employee Attestation Form: Use this form to certify that all employees and other provider personnel are not excluded or otherwise prohibited from participating in any state or federal healthcare program. This form needs to be attested and sent to Monroe Plan yearly.
- HIV Attestation Form: Use this form when attesting that you agree that you are an accredited HIV Provider. This form needs to be attested and sent to Monroe Plan yearly. If you are not an accredited HIV Provider, then this form can be left out of the annual attestation packet.
- Ownership Disclosure Form: Use this form to attest disclosure of ownership and financial interest of the group or facility. This form needs to be attested and sent to Monroe Plan yearly.
Thank you for all you do for our members and our communities at large.
Provider Relations & Network Management
TO: Participating Monroe Plan IPA and YourCare IPA Network Providers
FROM: Monroe Plan for Medical Care and YourCare IPA Provider Relations Department
DATE: May 8, 2023
SUBJECT: Provider Can Help Patients Stay Covered
Help Your Patients Keep Their Health Insurance
Medicaid, Essential Plan, Child Health Plus Benefits
Some of your patients could lose their NY State of Health Medicaid Managed Care, Child Health Plus or Essential Plan benefits if they do not complete their recertification paperwork on time. Unfortunately, your patients may not be familiar with the recertification process or how it applies to them.
We are asking for your help to boost awareness if you provide care and services to Molina members in the following plans: Molina Health Care of New York Medicaid Managed Care (MMC) Health Plan, Molina Healthcare PLUS Health Plan, Child Health Plus (CHPlus) Health Plan, or Essential Plan
Providers can play an important role in helping to keep their patients’ coverage without interruption. Please check your patients’ renewal (recert) date by going to the Molina Provider Portal (if you have not registered for the Molina provider portal, please visit this link: Molina Provider Portal and accessing the patient and eligibility details. You can also remind your patients that they will need to keep their health insurance to avoid any gaps in coverage. For more information visit: Renew My Coverage | Molina Healthcare of New York)
If members need more information they can call: Molina Healthcare at (844) 239-4911Y:711).
Thank you for all you do for our members and our communities at large.
Provider Relations & Network Management
Network Compliance
Mainstream Medicaid Managed Care Providers are required to ensure the cultural competence of practice staff and to certify annual completion of New York State approved cultural competence training curriculum. The approved training, titled Think Cultural Health, offers several provider specific programs online, at no cost: https://thinkculturalhealth.hhs.gov/education. Providers and appropriate staff should complete this training in the next 12 months and annually thereafter. Once finished, please share your certificate of completion with us at providerrelations@monroeplan.com.
Be sure to review the bulletin and resource below to ensure cultural competency and compliance!
Thank you for your cooperation!