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[null,"Molina Healthcare of Ohio \nClaims Payment Systemic Errors ",null,null,null,"June 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. Please 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: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 6/26/2024","ETA 9/19/2024","Ongoing \nremediation"]
["Unique ID:304\nConfirmed 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","55-Waivered Services, Individual , 45-Waivered Services Organization","2024-03-11","\nWorkaround Started 12/26/2023\nAdjustment 3 Complete - 5/13/2024\nAdjustment 2 Complete - 5/13/2024\nAdjustment 1 Complete - 5/19/2024","Complete"]
["Unique ID: 320\nPotential 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.\nAfter final review, not a CPSE. ","MyCare","2024-02-12","01-Hospital (Inpatient)","2024-02-15","After final review, not a CPSE. \n","Complete"]
["Unique ID: 322\nConfirmed CPSE\nE/M codes billed in conjunction with an acupuncture service rendered by the same provider to the same individual on the same day have paid in error, when performed by an Acupuncturist. ","Medicaid & MyCare","2024-02-15","23-Acupuncturist","2024-04-28","\nRecovery Complete - 5/15/2024","Complete"]
["Unique ID: 324\nConfirmed CPSE\nClaims for HCBS waiver services are being denied inappropriately for modifiers. ","MyCare","2024-02-27","55-Waivered Services, Individual , 45-Waivered Services Organization","2024-02-27","Adjustment Complete - 6/4/2024","Complete"]
["Unique ID: 325\nConfirmed CPSE\nHospital outpatient claims are not paying the contracted rate with Molina for dates of service on and after 1/1/24. ","Medicaid","2024-02-27","01-Hospital (Outpatient)","2024-02-28","\nAdjustment ETA - 5/7/2024 - 6/19/2024\nRecovery ETA - 5/10/2024 - 6/24/2024","Fix is complete"]
["Unique ID: 328\nConfirmed CPSE\nMolina has identified an issue with CPT codes Q4107,Q4236 and Q4253 are denying incorrectly for an NDC number.  ","Medicaid & MyCare","2024-02-28","01-Hospital (Outpatient), 21-Professional Medical Group","2024-03-08","\nAdjustment Medicaid Complete - 5/2/2024\nAdjustment MMP Complete - 5/22/2024\n","Complete"]
["Unique ID: 330\nPotential CPSE\nEdit was denying A4351 in error for billing over the benefit amount of 200 per calendar month. The edit was set up with rolling days and not calendar days. ","Medicaid","2024-03-06","76-Durable Medical Equipment Supplier","2024-04-28","\nAdjustment ETA - 6/6/2024 - 7/19/2024","Fix is complete"]
["Unique ID: 331\nConfirmed CPSE\nEdit denying HPCPS codes H0005 and H0006  in error for exceeding the Medically Unlikely Edits (MUE) of 1 unit per day. ","Medicaid","2024-03-27","84-Ohio Department of Mental Health (Community Mental Health) Provider ","2024-04-22","\nAdjustment ETA - 5/8/2024 - 6/20/2024","Fix is complete"]
["Unique ID: 332\nConfirmed CPSE\nEdit denying Behavioral health services when billed with modifier GT in error. ","Medicaid","2024-04-04","12-Federally Qualified Health Center, 54-Licensed Independent Chemical Dependency Counselor, 95-ODADAS Certified/Licensed (SUD) Treatment Program, 84-Ohio Department of Mental Health (Community Mental Health) Provider , 42-Psychologist, Individual, 21-Professional Medical Group, 37-Licensed Independent Social Worker (LISW)","2024-05-20","\nAdjustment ETA - 6/6/2024 - 7/19/2024","Fix is complete"]
["Unique ID: 333\nConfirmed CPSE\nCPT 90671 paying in error because it was not configured as VFC. ","Medicaid","2024-04-08","21-Professional Medical Group","\n4/29/2024 ","ETA 12/23/2024","Fix is complete"]
["Unique ID: 334\nConfirmed CPSE\nClaims for OhioRISE members have paid and/or redirected in error causing over and under payments. ","Medicaid","2024-03-18","95-ODADAS Certified/Licensed (SUD) Treatment Program, 84-Ohio Department of Mental Health (Community Mental Health) Provider ","2024-04-29","\nAdjustment  Complete - 6/3/2024\nRecovery Complete - 5/16/2024","Complete"]
["Unique ID: 335\nPotential CPSE\nOptum has identified an issue with the surgical hierarchy for MDC 04 (Diseases and Disorders of the Respiratory System) in the ICD-10 Medicare DRG V41.0 Grouper and ICD-10 TRICARE MS DRG V41.0 Grouper. Due to this issue, MS DRG 166 (Other Respiratory System O.R. Procedures With MCC) is taking precedence over MS DRG 173/272* (Ultrasound Accelerated and Other Thrombolysis With Principal Diagnosis Pulmonary Embolism) which is causing certain claims to group to the incorrect DRG and receive incorrect reimbursement. Within the MDC 04 surgical hierarchy, MS DRG 173/272* takes precedence over MS DRG 16.\nAfter final review, not a CPSE. ","MyCare","\n4/2/2024 ","01-Hospital (Inpatient)","ETA 9/20/2024","After final review, not a CPSE.","Complete"]
["Unique ID: 336\nPotential CPSE\nNon-payable REV codes are not being excluded during pricing of inpatient DRG hospital claims. ","Medicaid","2024-04-24","01-Hospital (Inpatient)","ETA  10/14/2024","ETA 1/9/2025 ","Ongoing \nremediation"]
["Unique ID: 337\nPotential CPSE\nLTAC rate sheets are set to price on discharge and not admit date. ","Medicaid","2024-04-26","86-Nursing Facility","2024-05-30","ETA 1/13/2025 ","Fix is complete"]
["Unique ID: 338\nPotential CPSE\nCodes M0224 and Q0224 will be configured in Molina’s system after the required 20-day turnaround requirement from the 3M release date of 5/16/2024 for EAPG outpatient hospital and ASC claims only. ","Medicaid","2024-05-07","01-Hospital (Outpatient)","2024-06-11","ETA 1/22/2025","Fix is complete"]
["Unique ID: 339\nNew Potential CPSE\nH0040 is being denied against non BH providers, causing invalid denials.","Medicaid","2024-05-15","00-All provider types","2024-06-03","ETA 1/31/2025","Fix is complete"]
["Unique ID: 340\nNew Potential CPSE\nProviders receiving remit for VOID claims in error. ","Medicaid","2024-05-15","00-All provider types","ETA 11/4/2025","ETA 1/31/2025","Ongoing \nremediation"]
["Unique ID: 341\nNew Potential CPSE\nBehavioral Health rates for codes 99112, 99113, 96130, 96131, 96136 and 96137 were not included when loading the 1/1/24 updates. ","Medicaid","2024-06-10","95-ODADAS Certified/Licensed (SUD) Treatment Program, 84-Ohio Department of Mental Health (Community Mental Health) Provider ","ETA 11/27/2024","ETA 2/24/2025 ","Ongoing \nremediation"]