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[null,"Molina Healthcare of Ohio \nClaims Payment Systemic Errors ",null,null,null,"February 2024"]
["The current Claims Payment Systemic Errors (CPSEs) are listed below. Resolved issues previously reported will be removed from this log, and may be found in archived reports. \nPlease review the log for updates prior to contacting Provider Services at (855) 322-4079."]
["Unique ID and Description of CPSE","Line of Business","Date CPSE was First Identified","Billing Provider Type(s) Impacted by CPSE (select all that apply)","Timeline for Fixing CPSE","Date(s) and/or Date Span(s) of Corrected Claims Adjustments","CPSE Status"]
["Unique ID:282\nConfirmed CPSE:\nEmergency room claims for non-emergent usage were being reimbursed at a higher level of care instead of being down coded to lower level of care for E and M services  per OAC 5160-2-77.","Medicaid & MyCare","2023-07-13","01-Hospital (Outpatient)","2023-08-15","Adjustment Batch 1 completed 12/11/2023\nAdjustment Batch 2 completed 1/12/2024\nAdjustment Batch 3 completed 2/13/2024\nClaim adjustments took longer than 30 days due to the complexity of the issue. ","Complete"]
["Unique ID:286\nConfirmed CPSE:\nMolina’s claim loader experienced intermittent slowness which causes incomplete loads in the pre-adjudication database.","Medicaid & MyCare","2023-08-02","01-Hospital (IP & OP), 80-Independent Laboratory, 82-Ambulance, 76-Durable Medical Equipment Supplier, 12-Federally Qualified Health Center, 51-Mental Health Clinic, 86-Nursing Facility, 21-Professional Medical Group, 45-Waivered Services Organization","2024-01-29","\nWorkaround started 8/18/2023","Complete"]
["Unique ID:290\nConfirmed CPSE:\nOptum has identified an issue with the Medicaid APG Pro Pricer when multiple significant procedure discounting is being erroneously applied to claims lines that should receive full payment.","Medicaid & MyCare","2023-08-10","01-Hospital (IP & OP)","2023-08-22","Adjustment ETA 1/12/2024 - 2/27/2024 \nRecovery Completed 1/22/2024","Fix is complete"]
["Unique ID:294\nPotential CPSE:\nOutpatient hospital claims for the provider Bon Secours Mercy/Mercy Health Partners of SW OH have paid at the incorrect rate. This issue may have potentially impacted the Medicaid claim when coordination of benefits was applied.","Medicaid & MyCare","2023-08-21","01-Hospital (Outpatient)"," 12/14/2023","ETA 5/6/2024","Fix is complete"]
["Unique ID:298\nConfirmed CPSE:\nHearing services paid incorrectly under the fee for services professional contracts.","Medicaid & MyCare","2023-09-26","76-Durable Medical Equipment Supplier","2023-12-04","\nCost Recovery ETA 2/12/2024-3/26/2024","Fix is complete"]
["Unique ID:299\nConfirmed CPSE:\nMolina is incorrectly applying Patient Liability to claims when the member has a patient liability type is waiver or pro-rated waiver.  ","Medicaid & MyCare","2023-10-04","44-Hospice, 86-Nursing Facility","ETA 3/26/2024","ETA 6/19/2024","Ongoing \nremediation"]
["Unique ID:304\nPotential CPSE:\nWaiver claims are linking to incorrect authorizations. This is causing the authorized provider to have claims deny for units being exhausted prematurely. It is also allowing the other providers to be paid without confirmation there is an authorization on file for them.","Medicaid & MyCare","2023-11-09","00-All provider types","ETA 5/1/2024","ETA 7/26/2024","Ongoing \nremediation"]
["Unique ID:305\nPotential CPSE:\nBehavioral health claims are denying incorrectly as a duplicate when the same service is rendered to the same patient by the same practitioner on the same date of service when something else differs such as place of service or modifier. ","Medicaid","2023-10-30","84-Ohio Department of Mental Health (Community Mental Health) Provider ","2024-01-28","ETA 7/16/2024","Fix is complete"]
["Unique ID:306\nPotential CPSE:\nOptum has identified an issue with the capital Disproportionate Share (DSH) factor for hospitals located in an urban area that were reclassified as rural with 100 or more beds. Capital DSH payments are only made to urban hospitals with 100 or more beds. Previously, when a hospital was reclassified from urban to rural, it was not eligible for capital DSH payments. Per the FY 2024 IPPS Final Rule, for discharges occurring on or after October 1, 2023, hospitals with 100 or more beds in urban areas that are reclassified as rural are now eligible for capital DSH payments. This update was inadvertently not implemented.","Medicaid","2023-11-15","01-Hospital (Inpatient)","2023-11-09","ETA 8/1/2024","Fix is complete"]
["Unique ID: 307                                                                                                                          \nPotential CPSE                                                                                                                     \nER Claim lines/claims denying for no PA. ER Services should process without 205 or 367 firing.\nAfter final review, not a CPSE. ","Medicaid ","2023-11-27","01-Hospital (Outpatient)","2023-12-01","After final review, not a CPSE. ","Fix is complete"]
["Unique ID: 308                                                                                                                           \nPotential CPSE                                                                                                                    \nThe updated 10/1/2023 EAPG Covered Code List that added 37 procedure codes and end-dated 20 procedure codes and the Outpatient Behavioral Health Fee Schedule changes that added 6 new COVID-19 codes will be configured in Molina’s system after the required 20-day turnaround requirement from the 3M release date of 11/16/23.   ","Medicaid ","2023-11-22","00-All provider types ","2023-12-12","ETA 8/8/2024 ","Fix is complete"]
["Unique ID: 309                                                                                                                          \nPotential CPSE                                                                                                                    \nFor outpatient facility claims only, the COVID and RSV code changes on the provider-administered pharmaceutical fee schedule received 11/13/2023 will be updated in Molina’s system beyond the 20-day turnaround requirement. ","Medicaid ","2023-11-22","01-Hospital (Outpatient)","2023-12-12","ETA 8/8/2024 ","Fix is complete"]
["Unique ID: 310                                                                                                                        \nConfirmed CPSE                                                                                                                   \nCMS updates to POA reporting on 9/30/2023 but the Molina system was not updated at the time. This is causing claim denials on claims with diagnosis codes Z62.29,  Z62.810, Z62,812 and Z62.819. An update request has been submitted. ","Medicaid ","2023-12-11","01-Hospital (Inpatient)","2024-01-01","\nAdjustment ETA 2/6/2024-3/19/2024","Fix is complete"]
["Unique ID: 311                                                                                                                         \nPotential CPSE                                                                                                                   \nIncorrect calculation for IP claims that contain diagnosis code U07.1 and either procedure code XW033E5 or XW043E5 that are also eligible for the new technologies add-on payment on the same claim.","Medicaid","2023-12-12","01-Hospital (Inpatient)","2023-11-21","ETA 8/27/2024","Fix is complete"]
["Unique ID: 312\nPotential CPSE \nNursing facility claims have been identified as overpaid due to not applying the patient liability in error. ","MyCare","2023-12-20","86-Nursing Facility","ETA 6/11/2024 ","ETA 9/5/2024 ","Ongoing \nremediation"]
["Unique ID: 313 \nPotential CPSE\nMolina policy is to allow E/M visits to bill immunizations without the requirement of a modifier, claims are denying for modifier not being appended.","Medicaid","2023-12-22","01-Hospital (Outpatient)","ETA 6/13/2024","ETA 9/9/2024 \n","Ongoing \nremediation"]
["Unique ID: 314\nNew Potential CPSE\nClaims for sleep study codes 95782, 95783, 95800, 95801, 95803 and 95806 incorrectly denied for prior authorization as they are not on Molina’s prior authorization list.","Medicaid & MyCare","2024-01-17","00-All provider types ","2024-02-02","ETA 9/30/2024","Fix is complete"]
["Unique ID: 315\nNew Confirmed CPSE\nCPT codes 96372, 99211, H2019, and T1002 with modifier HQ billed by a Registered Nurse in a mental health or substance use disorder agency paid incorrect rates and/or denied incorrectly causing underpayments.  ","Medicaid & MyCare","2024-01-26","95-ODADAS Certified/Licensed (SUD) Treatment Program, 84-Ohio Department of Mental Health (Community Mental Health) Provider ","2024-02-02","\nAdjustment ETA 2/13/2024-3/26/2024","Fix is complete"]
["Unique ID: 316\nNew Potential CPSE\nWhen the Med Policy configuration for CPT 90671 was updated as part of the July 2023 PAP Fee Schedule it was updated as non-covered under age 19 in error, causing claims to deny. ","Medicaid","2024-02-05","00-All provider types ","ETA 7/24/2024 ","ETA 10/17/2024","Ongoing \nremediation"]
["Unique ID: 317\nNew Potential CPSE\nDME code payment methodology for the following CPT codes (T5999, E8002, E8001, E8000, E0641, E0638, E0637, B4105, K1005, K0900, A9999 and A9900) were updated but claims may have been processed under the incorrect methodology. ","Medicaid & MyCare","2024-02-11","00-All provider types","ETA 7/30/2024 ","ETA 10/23/2024 ","Ongoing \nremediation"]
["Unique ID: 318\nNew Potential CPSE\nMedicare LTC claims assigned to MS-DRGs (880-887, 894-897 and 945-946) are receiving claim-level Pricer Error and, therefore, are not being reimbursed.  ","MyCare","2024-02-12","02-Psychiatric Hospital","ETA 7/31/2024 ","ETA 10/24/2024 ","Ongoing \nremediation"]
["Unique ID: 319\nNew Potential CPSE\nThe October 1, 2023 Radiopharmaceutical and Contrast Agent APC offset amounts were inadvertently used instead of the January 1, 2024 offset amounts. As a result, any Medicare outpatient claim assigned to the following APC's (5054-5055, 5571-5573, 5591-5594 and 5722) are being paid incorrectly.","MyCare","2024-02-12","01-Hospital (Outpatient)","ETA 7/31/2024 ","ETA 10/24/2024 ","Ongoing \nremediation"]
["Unique ID: 320\nNew Potential CPSE\nMolina has identified an issue with the Costs per Discharge rates for Medicare Dependent Hospitals (MDHs) and Sole Community Hospitals (SCHs). MDH/SCH claims are being reimbursed incorrectly when the operating hospital-specific rate is greater than the comparable operating federal-specific payment amount.","MyCare","2024-02-12","01-Hospital (Inpatient)","ETA 7/31/2024 ","ETA 10/24/2024 ","Ongoing \nremediation"]