Medicaid Payment Integrity Payment Policies
Molina Healthcare Medicare and Marketplace Payment Integrity Payment Policies
For Molina Healthcare Active Medicare and Marketplace, Please click the link.
Molina Healthcare Medicare and Marketplace Payment Integrity Payment Policies- New-Pending Emergency E&M Codes and Place of Service 23
- New-Pending Incarceration Diagnosis Code
- New-Pending Hospice Value Code 61
- Ambulatory Echocardiograph Monitoring
- Anesthsia Bundling
- Aortography and Peripheral Angiography
- Colonoscopies and Sigmoidoscopy
- Discontinued Procedures
- Hydrolyzed Enteral Formula Diagnosis
- Inpatient services billed on Outpatient bill types
- Injection and Infusions in the ER with 25 Modifier
- Medically Unlikely Edits
- Modifiers XE XS XP XU and 59 Usage
- Multiple EM codes for the same provider same date of service
- NPFS Status Indicator T
- Modifier 26
- Modifier KX
- Modifiers XE XS XP XU and 59 Usage
- Multiple Procedure Payment Reduction
- Non-Invasive Abdominal/Visceral Vascular Studies
- Polysomnography Studies and Home Sleep Testing
- Psychotherapy Add On with High Level EM
- Pulmonary Function Testing
- Reduced Services and Discontinued Procedures
- PT/OT Initial Evaluations
- PT/OT/ST Yearly Limit
- Status Indicator Flag B Bundled Codes
- Therapy Modifier Coding
- Unspecified Codes in an Inpatient Setting
New-Pending Policies
Existing Policies
- New-Pending Diagnosis Code Y65.XX
- New-Pending Optum EDC Analyzer - Facility ER E&M Leveling Prepayment
- Appropriate Level of Care Reimbursement
- BRCA1 and BRCA2 Genetic Testing
- Breast Cancer Genetic Testing Tier 1 vs Tier 2
- Critical Care Codes when Discharging Home from the Emergency Department
- Diagnosis Code Coding
- DRG Clinical Validation
- Excludes 1 Note
- Facility Emergency Department Evaluation and Management leveling
- High Level Evaluation and Management with Preventive Medicine
- High Dollar Pharmacy
- Hospital Routine Supplies Services
- Hospice
- ICD-10 Specificity Coding Policy
- ICD-10 First Listed Diagnosis Coding Policy
- Newborn and NICU
- Readmission
- Sepsis
- Semiprivate Vs Private Room
- Split-Night-Sleep-Study
- Overlapping Room and Board
- Optum Pause and Pay
- Observation
New-Pending Policies
Existing Policies
- New-Pending Diagnosis Code Y65.XX
- New-Pending Optum EDC Analyzer - Facility ER E&M Leveling Prepayment
- Allergen Testing
- Allergy Test
- ANA ENA Testing
- BHemolytic Streptococcus Testing
- Biochemical Markers of Alzheimer Disease and Dementia
- Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
- Bone Turnover Markers Testing
- Cardiac Biomarkers for Myocardial Infarction
- Cardiovascular Disease Risk Assessment
- Celiac Disease Testing
- Cervical Cancer Screening
- Diagnosis of Idiopathic Environmental Intolerance
- Diagnosis of Vaginitis Including Multi Target PCR Testing
- Diagnostic Testing of Common Sexually Transmitted Infections
- Diagnostic Testing of Influenza
- Diagnostic Testing of Iron Homeostasis and Metabolism
- Evaluation of Dry Eyes
- Epithelial Cell Cytology In Breast Cancer Risk Assessment
- Erectile Dysfunction
- Helicobacter pylori Testing
- Hemoglobin A1c
- Hepatitis C
- Immune Cell Function Assay
- Immunohistochemistry
- Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
- In Vitro Chemoresistance and Chemosensitivity Assays
- Intracellular Micronutrient Analysis
- Laboratory Procedures Reimbursement
- Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
- Lab Panel
- Labs Overlapping with Facility
- Metabolite Markers of Thiopurines Testing
- Non-Invasive Prenatal Testing
- Nerve Fiber Density Testing
- Onychomycosis Testing
- Pancreatic Enzyme Testing for Acute Pancreatitis
- Pathogen Panel Testing
- Physician Office Laboratory Testing
- Plasma HIV1 and HIV2 RNA Quantification for HIV Infection
- Preventive Screening in Adults
- Prostate Biopsies
- Prostate Specific Antigen PSA Testing
- Respiratory Pathogen Panel Test
- Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
- Serum Tumor Markers for Malignancies
- ST2 Assay for Chronic Heart Failure
- Salivary Hormone Testing
- Testosterone Testing
- Testing for Alpha 1 Antitrypsin Deficiency
- Testing for Diagnosis of Active or Latent Tuberculosis
- Testing for Mosquito- or Tick-Related Infections
- Thyroid Disease Testing
- Urinary Tumor Markers For Bladder Cancer
- Urine Culture Testing For Bacteria
- Vectra DA Blood Test for Rheumatoid Arthritis
- Venous and Arterial Thrombosis Risk Testing
- Vitamin B12 and Methylmalonic Acid Testing
- Vitamin D Testing
- ZIKA Virus Risk Assessment
New-Pending Policies
Existing Policies
- Advance Beneficiary Notice (ABN) Modifiers GA, GX, GY and GZ
- After Hours and Weekend Care Professional
- Corrected Claims
- Duplicate Claims
- Fee Schedule
- General Coding
- Post Pay General
- Paid Amount Exceeded Billed Amount
- Post-Pay Authorization Audit
- Medical Supplies Home Health Consolidated Billing
- Molina Healthcare Billing Requirements
- Molina Healthcare Cross-Departmental Audit and Recovery
- Molina Healthcare Audit/Recovery: Variable Discount Payments for Providers
- Molina Healthcare: Audit/Recovery for Revenue to CPT Code Review
- Molina Healthcare Audit Recovery for Billed Units
- Molina Healthcare Audit.Recovery for CPT to CPT Code
- Molina Healthcare Audit.Recovery for Diagnosis Codes
- Payment Policy 80 Fee Schedule
New-Pending Policies
Existing Policies
- DME KF Modifier
- DME Non-Invasive Ventilator Settings
- DME Place of Service 31 or 32
- DME Place of Service separately reimbursable
- DME Rental Vs Purchase
New-Pending Policies
Existing Policies
- New-Pending ESRD Billing for J0406 or J0606 with Modifier AX
- New-Pending ESRD Consolidated Billing
- New-Pending ESRD 90999 No Modifer (Weekly and Monthly) Limits
New-Pending Policies
Existing Policies
- Ambulance Modifier
New-Pending Policies
Existing Policies
- New-Pending Electrocardiographic EKG or ECG Monitoring Holter or Real Time Monitoring
- Ambulance Modifier
- Autonomic Function Testing
- CT (Computed Tomography) of the Abdomen and Pelvis
- Image Guided Radiation Therapy Coding
- Radiology Bone Density
- Radiology for Chest
New-Pending Policies
Existing Policies