Molina Provider Data Validation Survey

1.*Provider Information

Name of Practice

TIN:

NPI:

Address:

Service Location Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:

2.Hours of Operation:
NOTE: This question is for Primary Care Providers (PCP's) 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: This question is for Primary Care Providers (PCP's) only, all other provider types please skip to question 6.

Yes

4.Do you allow walk-in's during office hours?
NOTE: This question is for Primary Care Providers (PCP's) only, all other provider types please skip to question 6.

Yes

Other (please specify)

5.Are you taking new patients?
NOTE: This question is for Primary Care Providers (PCP's) only, all other provider types please skip to question 6.

Yes

6.*Our Provider Portal is know as "Availity Essentials," are you registered for Availity?

Yes

7.*Do you receive the Provider Bulletin?

Yes

If you do not already receive the Provider Bulletin via email, please provide your email address if you would like to sign up for our email distribution.

8.*Do you offer Telehealth Services?

Yes

9.*Do you use an Electronic Health Record (EHR)

Yes

If yes, please specify?

10.*Do you participate in a Health Information Exchange (HIE)?

Yes

If yes, please specify?

11.*Do you use Electronic Funds Transfer (EFT)?

Yes

12.*Do you utilize Electronic Data Interchange (EDI)?

Yes

13.*Are you aware of the process to submit an authorization or claim reconsideration via the Availity Essentials Portal?

Yes

14.*Do you know how to find information on upcoming Molina Trainings available for our provider community?

Yes

15.Do you know how to find information on relevant trainings via our You Matter to Molina page on our website?

Yes

16.*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?

Yes

If no, please specify reason why:

17.*Along with the link to this data validation survey, your Molina Provider Relations Manager sent you an affiliations roster for your review and attestation. Based on your review, please click the following statement that applies:

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 new V12 "join our network" tab found via the link: https://pwssc-cm.molinahealthcare.com/providers/mi/medicaid/comm/Join-Molina-Healthcare-of-Michigan-Network.aspx and follow the instructions on the website to complete the required updates with Molina Healthcare.

18.Do you have any other comments, questions, or concerns?

19.*Contact Information

Name of Person
Completing Survey:

Title:

Phone Number:

Address:

Molina Provider Data Validation

Molina Healthcare of Michigan