Overview of changes 

Based on feedback received from the Molina provider community regarding the multiple options to select from when submitting a reconsideration or appeal, Molina has streamlined the options in Availity to simplify the selection process for you. There are now only two options to select from: 

• Claim Payment Inquiry/Reconsideration
• Claim Payment Dispute/Appeal

Details of the updated options 

A Claim Payment Inquiry or Reconsideration is a review of a claim you believe was paid or denied incorrectly due to a minor error. These inquiries are typically straightforward and can be quickly resolved. This option consists of the following categories:

1. Reconsideration – Authorization 
2. Reconsideration – Eligibility 
3. Reconsideration – Pricing Review 
4. Reconsideration – Other

Examples to use this option include: 

• Retro-eligibility issues
• Coordination of benefit updates
• Claims denied as a duplicate in error
• Claims denied for no authorization when authorization is not required or when an approved authorization is on file

Please note that you cannot submit supporting documentation with a claim payment inquiry. The outcome of a payment inquiry may result in either a claims adjustment or a directive to submit a Corrected Claim or initiate the Claim Payment Dispute/Appeal process.

Click here to read the full announcement from Molina.