rs work with its pharmacy benefits manager to maintain a formulary that promotes both improved patient care and generic drug use. Provider Network and Contract Management: In partnering with providers, the company utilizes clinical and financial information derived by its medical informatics function, as well as the experience that the company has gained in serving Medicaid members, to gain insight into the needs of both its members and its providers. Provider Networks The company arranges health care services for its members through contracts with providers that include independent physicians and groups, hospitals, ancillary providers, and its own clinics. The company’s network of providers includes primary care physicians, specialists, and hospitals. The company’s strategy is to contract with providers in those geographic areas and medical specialties necessary to meet the needs of its members. Physicians: The company contracts with both primary care physicians and specialists, majority of whom are organized into medical groups or independent practice associations. Primary care physicians provide office-based primary care services. The company’s specialists care for patients for a specific episode or condition, usually upon referral from a primary care physician, and are usually compensated on a fee-for-service basis. Hospitals: The company contracts with hospitals that have experience dealing with the medical needs of the Medicaid population. The company reimburses hospitals under various payment methods, including fee-for-service, per diems, diagnostic-related groups capitation, and case rates. Direct Delivery: The clinics that the company operates are located in neighborhoods where its members live, and provide the company a first-hand opportunity to understand the special needs of its members. The clinics that the company operates assist the company in developing and implementing community education, disease management, and other programs. Management Information Systems All of the company’s health plan information technology systems operate on a single platform. The ePortal allows various self-services. Provider Self Services - Providers have the ability to access information regarding their members and claims. Key functionalities include ‘Check Member Eligibility’, ‘View Claim’, and ‘View/Submit Authorizations’. Member Self Services - Members can access information regarding their personal data, and can perform the key functionalities, such as ‘View Benefits’, ‘Request New ID Card’, ‘Print Temporary ID Card’, and ‘Request Change of Address/PCP’. File Exchange Services - Various trading partners, such as service partners, providers, vendors, management companies, and individual IPAs, are able to exchange data files (such as those that might be required by federal health care privacy regulations, or any other proprietary format) with the company using the file exchange functionality. Claims Processing: All of the company’s health plans operate on a single managed care platform for claims processing (the QNXT system). Centralized Management Services: The company provides certain centralized medical and administrative services to its health plans pursuant to administrative services agreements, including medical affairs and quality management, health education, credentialing, management, financial, legal, information systems, and human resources services. Fees for such services are based on the fair market value of services rendered. Growth Strategy The company’s growth strategy includes growing and retention in its existing markets; expansion into new geographies; transitioning members and benefits from fee for service to managed care; and developing and acquiring new products and capabilities. Regulatory Compliance All health plans are subject to the Health Insurance Portability and Accountability Act, including the company. The company’s operations are subject to various state and federal health care laws commonly referred to as ‘fraud and abuse’ laws, including the federal False Claims Act. Intellectual Property The company has registered and maintains various
molina healthcare inc (MOH:New York)
Long Beach, CA 90802
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