Molinalogo

Individuals are eligible for Senior Whole Health plans if they:

• Are 65 years old or older
• Have Medicare & MassHealth Standard (dual eligible) or have MassHealth Standard
• Live in our service area

To check Member Eligibility: please log into our Provider Portal.

To Register for Availity please click here.

The most efficient way to check member eligibility is through Availity or the option below:

• NewMMIS, formerly known as REVS
  • Log in to Provider Online Service Center (POSC)
    • Click Manage Members/Eligibility, and look up patient by SSN or name and DOB
    • In the List of Managed Care Data (for MCO) section, choose Senior Whole Health
  • Registration is free for MassHealth Providers
  • For registration and other information, visit Mass.gov/masshealth or call
    (800) 841-2900 (this number may also be used to access the IVR system)

Advantages to using these online tools:

• Prompt, 24/7 access
• Unlimited number of inquiries
• Ability to confirm single dates of service and date ranges
• Easily print eligibility confirmation for your records

You can also call for eligibility at (855) 838-7999.

We cover benefits provided by network providers without referrals.

For a complete list of member benefits, limitations and requirements, please refer to the Senior Whole Health Evidence of Coverage and Summary of Benefits

For medical services requiring prior authorization, complete the Standard Prior Authorization Request Form and fax it to the appropriate level of care contact.

All inpatient authorization requests must include clinical information. You may fax in clinical information to 844-834-2152 with the appropriate form or call (855) 838-7999.

To get prior authorization for prescription drugs, you may request coverage:

• Online using the Medicare Prescription Drug Coverage Determination Form

   

More information on concurrent and retroactive authorizations is available in the Provider Manual.

You may use the means above to request Formulary exceptions, including asking for a drug not listed on the formulary or to waive a restriction such as quantity limits, prior authorizations and step therapy.

Senior Whole Health encourages providers to report fraud or suspected fraud by calling the Molina AlertLine: Call: (866) 606-3889 TTY: 711 (for the hearing impaired) Online: secure.ethicspoint.com/domain/media/en/gui/75190/

For more information on fraud, waste and abuse, refer to your Provider Manual

How to submit provider rosters and roster updates

Please read the following rules and guidelines for submitting rosters and roster updates.

• All provider rosters submitted for processing must include a complete listing of par providers associated with:
• Participating group practices of 5 or more providers
• IPAs
• Hospitals and hospital systems
• PHOs, IDNs and other contractual relationships that include multiple providers (practitioners and/or facilities)
• In order to comply and maintain within the CMS and State Medicaid regulatory requirements, providers should submit a full comprehensive roster on an annual basis and add/change roster on a quarterly basis. (once every 3 months)
• The purpose of the roster is to communicate provider additions, terminations and changes submitted on a monthly basis and must contain a minimum of 5 + providers. Any add/changes to a roster must be received at least 30 days in advance of the effective date request to allow the provider that require credentialing to be enrolled prior to seeing members.

Updates submitted for fewer than 5 providers will not be accepted. Please see the section titled How to submit provider maintenance tasks for updates to individually contracted providers and groups of fewer than 5.

• All provider rosters and provider roster updates must be submitted using the Excel spreadsheet template below and include all the required data elements.

Senior Whole Health Roster Template

• Any roster, roster update or provider data maintenance request that does not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
• Completed requests should be saved using the following file naming conventions: <provider name_date>.xls

Example file names:
Group Practice: ABCPediatrics_01012020
Health System, IPA, PHO: BaptistHealthSystem_01012020

• Email completed rosters, roster updates and provider data maintenance files/forms to SWHProviderRelations@molinahealthcare.com.
• All provider rosters, roster updates and data maintenance tasks including the required data elements will be processed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.

How to submit provider maintenance tasks

Individually contracted providers (solo practitioners/facilities) and group practices with fewer than 5 providers can update their demographic information by submitting a provider maintenance task.

• Provider maintenance tasks can be submitted each month (as needed) by downloading and completing the following Excel spreadsheet template.

Senior Whole Health Roster Template

• Provider data maintenance tasks that do not contain all required data elements will be returned to the contracted provider entity (submitter) to append the missing information.
• Completed requests should be saved using the following file naming conventions.
  
  

Example file names:
Individual Provider: JohnSmith_01012020
Small Group Practice: ABCPediatrics_01012020

Please note groups must be less than 5 providers

• Email provider data maintenance files to SWHProviderRelations@molinahealthcare.com.
• Please utilize the Provider Information Update Form
• All provider data maintenance forms will be completed within 30 calendar days from the date of receipt (via email). Upon completion, an email confirmation will be sent to the address provided on the original request.