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!

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* 1. Provider Information

Name of Practice

Tax Identification Number (TIN)

Address

City

State

Zip Code

Phone Number

Fax Number

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* 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

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* 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

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* 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

Other (please specify)

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* 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

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* 6. Are you registered on the Availity Essentials Portal?

Yes

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* 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.

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* 8. Do you offer Telehealth?

Yes

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

Yes

If yes, which one?

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

Yes

If yes, which one?

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

Yes

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

Yes

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

Yes

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* 14. Do you know how to find information on upcoming Molina trainings available to your practice and the monthly You Matter to Molina Provider Forum?

Yes

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* 15. 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, I attest

No, I do not attest

N/A

If no, please include reason below:

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* 16. 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:

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.

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

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* 18. Contact Information

Name of Person Completing Survey

Title

Phone Number

Email Address

Molina Provider Data Validation

Molina Healthcare

Question Title

* 1. Provider Information

Question Title

* 2. Hours of Operation:Note: This question is for Primary Care Providers only, all other provider types please skip to Question 6.

Question Title

* 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.

Question Title

* 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.

Question Title

* 5. Are you taking new patients?Note: This question is for Primary Care Providers only, all other provider types please skip to Question 6.

Question Title

* 6. Are you registered on the Availity Essentials Portal?

Question Title

* 7. Do you receive the Provider Bulletin?

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* 8. Do you offer Telehealth?

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 14. Do you know how to find information on upcoming Molina trainings available to your practice and the monthly You Matter to Molina Provider Forum?

Question Title

* 15. 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?

Question Title

* 16. 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:

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

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* 18. Contact Information

* 2. Hours of Operation:
Note: This question is for Primary Care Providers only, all other provider types please skip to Question 6.

* 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.

* 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.

* 5. Are you taking new patients?
Note: This question is for Primary Care Providers only, all other provider types please skip to Question 6.