Process your claims more eficiently and most importantly ...

Molina Healthcare of South Carolina (MHSC) is required by its contracts with the SC Department of Health and Human Services and the Centers for Medicare and Medicaid (CMS), to maintain accurate Provider Directories that demonstrate its network Provider availability and facilitate access to its Providers by its Members. Additionally, when we have your accurate and correct information, we are able to process your claims more efficiently and most importantly, correctly!

To comply with its contract requirements, and to ensure customer satisfaction, MHSC recently implemented a verification process to confirm the validity of the information contained in its Provider Directories. Accuracy of this information is important for MHSC, as well as its Providers and Members.

If you do not have an existing roster, please use the attached form to submit your practice demographic information, and we will make any appropriate updates in our system. Please also include a copy of your current W-9. You may return this form in any of the following ways:

Via fax: (844) 305-2343

Via email: MHSCPODValidation@

MHSC requires notification to the health plan for specific circumstances. As it relates to Provider demographic information, Providers are required to notify MHSC with any of the following changes:

? Changes in practice ownership, name, address, phone number, Tax Identification Number or NPI number.

? Addition of a new practitioner to the group practice, or a new service location. ? If terminating your affiliation with MHSC, in accordance with the provisions of your

Provider agreement.

To ensure the accuracy of our directories, Providers are reminded to notify MHSC when these changes occur. If you have any questions regarding this communication, please contact Provider Services at (855) 237-6178.

*For clarification purposes, the Medical Group Affiliate attribute on the form attached is the pay to

name for the provider or to whom the MCO names in the payments for rendered services and the

Hospital Affiliate is the hospital the provider has admitting privileges.

*Molina's best practices suggest providers review our provider online directory to confirm

physician and/or facility information is displaying properly for members.

*You may be contacted to submit required materials depending upon requested changes.

*If you have submitted updated information to Molina in the last 6 months, you may disregard.

Sincerely,

Jennifer Marze Director, Provider Services Molina Healthcare of South Carolina

4342809SC0318

Provider Demographics Form

Fax to (844) 305-2343

Elements

Name Individual NPI

Individual Provider Information

Facility Information

Group NPI Group Tax ID

Email Gender

Specialty Hospital affiliations

Medical group affiliations Board certification

Accepting new patients (Y/N) Languages spoken

Office location (address) Phone numbers

Office hours

Accepted ages (age range accepted)

Gender restrictions (M/F/None) Office ADA accessible

*If you have any questions regarding this information, please contact Provider Services at (855) 237-6178. *Molina's best practices suggest providers review our provider online directory to confirm physician and/or facility information is displaying properly for members.

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