May 14, 2024
Reminder that balance billing is not allowed
Molina Healthcare of Wisconsin, Inc. (Molina) reminds providers that they are prohibited from balance billing members for covered services other than the member’s applicable copayment, coinsurance or deductible amounts. Covered services include health care services and supplies, including emergency services provided to members that are medically necessary and covered by Molina as a member benefit.
Also, the provider is responsible for verifying eligibility and obtaining approval for services that require Prior Authorization (PA). You can use the Availity Essentials portal to verify membership and coverage. Molina’s website features several PA resources, including the quarterly PA Codification Lists and the PA LookUp Tool.
Providers agree that under no circumstance shall a Molina member be liable to the provider for any payment owed that is the legal obligation of Molina.
Note: Molina strongly recommends that providers ask patients if they have multiple forms of health insurance when verifying their coverage.
Examples of balance billing include:
- Holding members who are dually eligible for Medicare and Medicaid liable for Medicare Part A and B cost-sharing
- Requiring Molina members to pay the difference between the discounted and negotiated fees and the provider’s usual and customary fees
- Charging Molina members fees for covered services beyond copayments, deductibles or coinsurance
- Requiring members to pay for a covered service that was denied or rejected by the health plan for valid/appropriate reasons
Providers are encouraged to review balance billing material in the Provider Manual and in their agreement with Molina.
Please reach out to your Provider Relations Manager with questions or contact the team at MHWIProviderNetworkManagement@molinahealthcare.com.