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[null,"Molina Healthcare of Ohio \nClaims Payment Systemic Errors ",null,null,null,"April 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: 294\nConfirmed 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","Adjustment completed 4/10/2024\nRecovery Batch 1 completed 4/4/2024\nRecovery Batch 2 completed 4/4//2024\n","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 6/26/2024","ETA 9/19/2024","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","21-Professional Medical Group","2024-03-11","ETA 7/26/2024\nWorkaround Started 12/26/2023","Fix is complete"]
["Unique ID: 305\nConfirmed 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","Adjustment ETA 3/21/2024 - 5/2/2024","Fix is complete"]
["Unique ID: 306\nConfirmed 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","Adjustment completed 3/28/2024","Complete"]
["Unique ID: 308                                                                                                                           \nConfirmed 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","01-Hospital (Outpatient)","2023-12-12","Adjustment completed 3/28/2024","Complete"]
["Unique ID: 309                                                                                                                          \nConfirmed 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","Adjustment completed 3/28/2024","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.\nAfter final review, not a CPSE.","Medicaid","2023-12-12","01-Hospital (Inpatient)","2023-11-21","After final review, not a CPSE. ","Complete"]
["Unique ID: 313 \nConfirmed 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)","2024-04-01","Adjustment ETA 4/8/2024 - 5/20/2024\n","Fix is complete"]
["Unique ID: 314\nConfirmed 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","01-Hospital (Outpatient), 21-Professional Medical Group","2024-02-02","Adjustment ETA 3/26/2024 -  5/7/2024","Fix is complete"]
["Unique ID: 315\nConfirmed 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.  \n","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 completed 3/22/2024","Complete"]
["Unique ID: 316\nConfirmed 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 ","2024-02-16","Adjustment ETA 3/20/2024 - 5/1/2024","Fix is complete"]
["Unique ID: 318\nPotential 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.  \nAfter final review, not a CPSE. ","MyCare","2024-02-12","02-Psychiatric Hospital","2024-02-15","After final review, not a CPSE. ","Complete"]
["Unique ID: 319\nPotential CPSE\nThe October 1, 2023 Radiopharmaceutical and Contrast Agent APC offset amounts were inadvertently used instead of the January 01, 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.\n","MyCare","2024-02-12","01-Hospital (Outpatient)","2024-02-15","ETA 10/24/2024 ","Fix is 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.\n\n","MyCare","2024-02-12","01-Hospital (Inpatient)","2024-02-15","ETA 10/24/2024 ","Fix is complete"]
["Unique ID: 322\nPotential 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. \n\n","Medicaid & MyCare","2024-02-15","23-Acupuncturist","ETA 8/5/2024 ","ETA 10/29/2024","Ongoing \nremediation"]
["Unique ID: 323\nPotential CPSE\nNon Par/Out-of-state Children’s and Teaching hospital claims were configured to pay the incorrect default rates.\nAfter final review, not a CPSE. \n  \n\n","Medicaid","2024-02-19","01-Hospital (IP & OP)","2024-02-20","After final review, not a CPSE. ","Complete"]
["Unique ID: 324\nPotential CPSE\nClaims for HCBS waiver services are being denied inappropriately for modifiers. \n  \n\n","MyCare","2024-02-27","00-All provider types","2024-02-27","ETA 11/8/2024","Fix is 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","ETA 11/8/2024","Fix is complete"]
["Unique ID: 327\nPotential CPSE\nThe benefit for CPT code 99078 with modifier TH (group pregnancy education) is limiting to 6 sessions per pregnancy instead of 10. ","Medicaid","\n2/23/2024","21-Professional Medical Group","ETA 8/13/2024","ETA 11/6/2024","Ongoing \nremediation"]
["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","21-Professional Medical Group","2024-03-08","Adjustment ETA Medicaid 3/21/2024 - 5/2/2024\nAdjustment ETA MMP 3/28/2024 - 5/9/2024","Fix is complete"]
["Unique ID: 329\nPotential CPSE\nThe January 1, 2024 HCBS waiver rates were not updated for A0080, A0090, G0155, S5130, S9470, T2003, T2025 codes for ICDS, Assisted Living and Passport/Choices Waivers causing incorrect payments. \nAfter final review, not a CPSE. ","Medicaid & MyCare","2024-02-27","00-All provider types","2024-04-03","After final review, not a CPSE. ","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","ETA 8/23/2024","ETA 11/18/2024","Ongoing \nremediation"]
["Unique ID: 331\nNew Potential 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","00-All provider types","ETA 9/16/2024","ETA 12/11/2024","Ongoing \nremediation"]
["Unique ID: 332\nNew Potential CPSE\nEdit denying Behavioral health services when billed with modifier GT in error. ","Medicaid","2024-04-04","00-All provider types","ETA 9/24/2024 ","ETA 12/18/2024","Ongoing \nremediation"]
["Unique ID: 333\nNew Confirmed CPSE\nCPT 90671 paying in error because it was not configured as VFC. ","Medicaid","2024-04-08","21-Professional Medical Group","ETA 9/26/2024 ","ETA 12/23/2024","Ongoing \nremediation"]
["Unique ID: 334\nNew Confirmed CPSE\nClaims for OhioRise members have paid and/or redirected in error causing over and under payments. ","Medicaid","2024-03-18","00-All provider types","ETA 9/5/2024 ","ETA 11/29/2024","Ongoing \nremediation"]
["Unique ID: 335\nNew Potential 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.","MyCare","\n4/2/2024 ","01-Hospital (Inpatient)","ETA 9/20/2024","ETA 12/16/2024","Ongoing \nremediation"]