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[null,"Molina Healthcare of Ohio\nClaims Payment Systemic Errors ",null,null,null,"November 2023"]
["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:269\nConfirmed CPSE:\nNew Marketplace fee schedule allowed payments for BH codes listed on the TPL bypass list to process for payment. Due to the new fee schedule and the configuration to allow those payments, claims that should pay as primary for 84/95 providers stopped paying as primary and only processed under the Medicaid line of business if Marketplace allowed patient responsibility resulting in the provider being underpaid.  ","Medicaid & \nMyCare","2023-04-17","84-Ohio Department of Mental Health (Community Mental Health) Provider \r\n95-ODADAS Certified/Licensed (SUD) Treatment Program","2023-07-06","Workaround started 4/24/2023\nAdjustment Batch 1 completed 10/5/2023\nAdjustment Batch 2 completed 10/4/2023\nAdjustment Batch 3 completed 10/13/2023\nRecovery Batch 1 completed 9/25/2023\nRecovery Batch 2 completed 10/11/2023","Complete"]
["Unique ID:282\nConfirmed CPSE:\nEmergency room claims for non emergent usage were being reimbursed at a higher level of care instead of being downcoded to lower level of care for E and M services per OAC 5160-2-77.","Medicaid & \nMyCare","2023-07-13","01-Hospital (Outpatient)","2023-08-15","\nAdjustment Batch 1 ETA 10/18/2023-11/29/2023\nAdjustment Batch 2 ETA 11/14/2023-12/28/2023\n","Fix is complete"]
["Unique ID:284\nConfirmed CPSE:\nProviders that submit claims with attachments through Availity, the submission is either completely missing the attachment or the attachment is being delay causing some claims to deny.","Medicaid & \nMyCare","2023-07-19","01-Hospital (Outpatient)","2023-08-08","Adjustment Batch 1 completed 9/12/2023\nAdjustment Batch 2 ETA 10/20/2023 - 12/5/2023","Fix is complete"]
["Unique ID:285\nConfirmed CPSE:\nBH providers with specialty listed of Nurse Practitioner claims are denying for Ordering Provider in error.","Medicaid & \nMyCare","2023-07-28","84-Ohio Department of Mental Health (Community Mental Health) Provider ","2023-09-25","Batch 1 Adjustment ETA 11/8/2023 - 12/20/2023\nBatch 2 Adjustment completed 11/10/2023","Fix is complete"]
["Unique ID:286\nConfirmed CPSE:\nMolina’s claim loader experienced intermittent slowness which causes incomplete loads in the pre-adjudication database.","Medicaid & \nMyCare","2023-08-02","21-Professional Medical Group\r\n95-ODADAS Certified/Licensed (SUD) Treatment Program","ETA 11/30/2023","Workaround started 8/18/2023","Ongoing \nremediation"]
["Unique ID:289\nConfirmed CPSE:\nInpatient claims with DOS that span before and after 07/28/23 are pricing incorrectly.\n","Medicaid & \nMyCare","2023-08-09","01-Hospital (Inpatient)","2023-09-05","\nAdjustment batch 1 completed 9/19/2023\nAdjustment batch 2 completed 9/7/2023\nAdjustment batch 3 and 4 completed 8/25/2023\nRecovery Batch ETA 12/27/2023","Fix is complete"]
["Unique ID:290\nPotential 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 & \nMyCare","2023-08-10","01-Hospital (IP & OP)","2023-08-22","ETA 2/6/2024","Fix is complete"]
["Unique ID:293\nConfirmed CPSE:\nOn 8/15/23, one of our vendors reported a system error affecting add-on codes causing them to deny in error. The configuration saver tool was used to load the Q3 Knowledgebase on 8/12/23, this caused the files to return errors.\n","Medicaid & \nMyCare","2023-08-15","84-Ohio Department of Mental Health (Community Mental Health) Provider \r\n95-ODADAS Certified/Licensed (SUD) Treatment Program\r\n12-Federally Qualified Health Center\r\n21-Professional Medical Group","2023-08-15","\n\nAdjustment Batch 1 completed 10/30/2023\nAdjustment Batch 2 completed 11/10/2023\n","Complete"]
["Unique ID:294\nPotential CPSE:\nOutpatient hospital Medicare 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.     \n","MyCare","2023-08-21","01-Hospital (Outpatient)","ETA 12/19/2023","ETA 2/17/2024","Ongoing \nremediation"]
["Unique ID:295\nConfirmed CPSE:\nOptum incorrectly calculating LTCH reimbursement for claims with a Thru or Discharge Date on or after 5/12/2023 and a From or Admission Date prior to 5/ 12/2023.\nAfter Final Review, NOT A CPSE ","Medicaid & \nMyCare","2023-09-06","01-Hospital (Inpatient)","2023-09-14","After Final Review, NOT A CPSE ","Complete"]
["Unique ID:297\nConfirmed CPSE:\nMMP Medicaid review was transferred in June 2022, from Ohio team to the MMP team, ACT attribute was not updated in QNXT resulting in claim denials. ","MyCare","2023-09-21","84-Ohio Department of Mental Health (Community Mental Health) Provider ","2023-10-16","\nAdjustment batch 1 completed 10/5/2023\nAdjustment batch 2 completed 10/23/2023","Complete"]
["Unique ID:298\nConfirmed CPSE:\nHearing services paid incorrectly under the fee for services professional contracts.","Medicaid & \nMyCare","2023-09-26","76-Durable Medical Equipment Supplier","ETA 3/21/2024","ETA 6/14/2024","Ongoing \nremediation"]
["Unique ID:299\nPotential CPSE:\nMolina is incorrectly applying Patient Liability to claims when the member has a patient liability type is waiver or pro-rated waiver.","Medicaid & \nMyCare","2023-10-04","86-Nursing Facility","ETA 3/29/2024","ETA 6/25/2024","Ongoing \nremediation"]
["Unique ID:300\nConfirmed CPSE:\nQNXT is not sending all of the Inpatient procedure codes to AMS XML file causing invalid denials. An update is set to be released at the end of 10/2023, edit will be turned off until we can confirm QNXT update is installed and tested to ensure all logic and file transfers are correct. ","Medicaid","2023-09-19","01-Hospital (Outpatient)","2023-10-23","\nAdjustment completed 11/1/2023","Complete"]
["Unique ID:301\nPotential CPSE:\nClaims incorrectly rejected for “Member Not Found” error. Claim routing process between Molina HPs and lines of business failed to recognize the member billed on the claim as a Molina OH claim because a key table used to look up the member information failed to update on different dates in 2023. ","Medicaid & \nMyCare","2023-09-01","00-All provider types","ETA 2/28/2024","ETA 5/22/2024","Ongoing \nremediation"]
["Unique ID:302\nPotential CPSE:\nOhio Medicaid outpatient claims are denying revenue code 250 lines for missing/incomplete/invalid procedure code. Per the Ohio Medicaid Hospital billing guidelines manual, no HCPCS is required for Ohio Medicaid claims when billed as outpatient.  ","Medicaid","2023-10-13","01-Hospital (Outpatient)","ETA 4/8/2024","ETA 7/3/2024","Ongoing \nremediation"]
["Unique ID:304\nNew Potential 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 & \nMyCare","2023-11-09","00-All provider types","ETA 5/3/2024","ETA 7/31/2024","Ongoing \nremediation"]
["Unique ID:305\nNew Potential CPSE:\nBehavioral health claims are denying incorrectly as a duplicate when the same service is rendered to the same patient by the same practictioner 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 ","ETA 4/23/2024","ETA 7/19/2024","Ongoing \nremediation"]