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Molina Provider Data Validation
Molina Healthcare
Molina Healthcare regularly completes validation of contact and demographic information of providers. We would appreciate your response to this brief survey.
This survey will take approximately 5-7 minutes to complete. Thank you!
OK
*
1.
Provider Information
(Required.)
Name of Practice
Tax Identification Number (TIN)
Group NPI
Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
2.
Hours of Operation:
Note: This question is for
Primary Care Providers
only, all other provider types please skip to Question 6.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
3.
Do you offer after hours appointments?
Note: Note: This question is for
Primary Care Providers only
, all other provider types please skip to Question 6.
Yes
No
4.
Do you allow walk-ins during office hours?
Note: This question is for
Primary Care Providers only
, all other provider types please skip to Question 6.
Yes
No
Other (please specify)
5.
Are you taking new patients?
Note: This question is for
Primary Care Providers only
, all other provider types please skip to Question 6.
Yes
No
*
6.
Are you registered on the Availity Provider Portal?
(Required.)
Yes
No
*
7.
Do you receive the Provider Bulletin?
(Required.)
Yes
No
Please provide your email address if you would like to sign up for our email distribution.
*
8.
Do you offer Telehealth?
(Required.)
Yes
No
*
9.
Do you use an Electronic Medical Record (EMR)?
(Required.)
Yes
No
If yes, which one?
*
10.
Do you participate in a Health Information Exchange (HIE)?
(Required.)
Yes
No
If yes, which one?
*
11.
Do you utilize Electronic Funds Transfer (EFT)?
(Required.)
Yes
No
*
12.
Are you aware of the process to submit an authorization or claim reconsideration via the Availity Provider Portal?
(Required.)
Yes
No
*
13.
Do you know how to find information on upcoming Molina trainings available to your practice and the monthly It Matters to Molina Provider Forum?
(Required.)
Yes
No
*
14.
For PCP, BH and Specialists: Do you attest to meeting/exceeding the appointment access and availability standards located in the "Quality Improvement" chapter of the Provider Manual, posted on the Provider Website at www.MolinaHealthcare.com?
(Required.)
Yes, I attest
No, I do not attest
N/A
If no, please include reason below:
*
15.
Along with the link to this data validation survey, your Molina Provider Services Representative sent you an affiliations roster for your review and attestation. Based on your review, please click the following statement that applies:
(Required.)
I have reviewed the affiliations roster and attest that all information is complete and accurate to the best of my knowledge.
I have reviewed the affiliations roster and some information requires updates. I will access the Provider Information Update Form available at www.MolinaHealthcare.com under the "forms" tab and follow the instructions on the form to complete the required updates with Molina Healthcare.
16.
Do you have any other comments, questions, or concerns?
*
17.
Contact Information
(Required.)
Name of Person Completing Survey
Title
Phone Number
Email Address
Current Progress,
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