2026 ConnectiCare Integration with Molina Healthcare

ConnectiCare’s new parent company is Molina Healthcare. Until we are fully integrated into the Molina family, network providers should continue to follow ConnectiCare’s existing policies and processes as posted on our website, and use our existing portal functions.

Beginning Jan. 1, 2026, ConnectiCare will have three lines of business: Commercial, Marketplace (Exchange), and Medicare.

• Commercial members will have an ID number that begins with the letter “K”. For these members, providers should continue to follow ConnectiCare’s existing policies and processes as posted on our website, and use our existing portal functions through the end of 2026.
• Marketplace members will have an all-numeric ID number with 3-9 digits. For these members, providers should follow ConnectiCare’s new operational changes as outlined below, beginning Jan. 1, 2026.
• Medicare members will have an ID number that may begin with the letter “K” or an all-numeric ID number with 13 digits that begins with the number eight. For these members, providers should also follow ConnectiCare’s new operational changes as outlined below, beginning Jan. 1, 2026.

Below is important information you’ll need to know to facilitate a smooth transition. For more details, refer to the 2026 Marketplace Provider Manual and 2026 Medicare Provider Manual.

Providers will use the Availity Essentials portal to perform many functions online with ConnectiCare for Marketplace and Medicare members. If you already use Availity Essentials with other health plans, you can continue to use the platform with ConnectiCare. You do not need to create a separate user account. If you do not currently use Availity Essentials, you can register for an account.

Availity Essentials is an easy-to-use tool that offers many features, including: 

• Verify member eligibility and covered services, view gaps in care.
• Submit claims with file attachments, check claim status, view electronic remittance advice and explanation of payments, correct/void claims, and submit claim appeals with file attachments. 
• Submit prior authorization requests for services (excluding vendor-managed services) with supporting documents, and check status of prior authorization requests.
• Download forms and documents. 
• Send/receive secure messages to/from ConnectiCare. 

Training on how to use Availity Essentials will be offered beginning in December 2025.

ConnectiCare will adopt Molina’s Marketplace and Medicare lists of services that require prior authorization. To search prior authorization requirements for specific codes, refer to the Prior Authorization LookUp Tool. It’s important to note:

• All elective inpatient services require prior authorization.
• Home health requires prior authorization:
  • After the first three 30-day episodes of care per calendar year for Medicare members.
  • After the first six visits per calendar year for Marketplace members.
• Physical therapy (PT), occupational therapy (OT), and speech therapy (ST) require prior authorization:
  • After the first 12 visits of each discipline per calendar year for Medicare members.
  • PT and OT after the first 12 visits of each discipline per calendar year for Marketplace members.
  • ST after the first six visits per calendar year for Marketplace members.

To submit a request to ConnectiCare for prior authorization of services not managed by a vendor, providers will use the Availity Essentials portal:

• Providers will no longer be required to address the MCG clinical guidelines criteria. Instead, providers will need to upload supporting clinical documentation.
• By including relevant information, providers will continue to receive expedited responses for advanced imaging requests while requests for other services like inpatient emergency admission and home health care may require more time.
• Determination letters will be issued to providers via the Availity Essentials portal. If you opt out of digital correspondence, letters will be sent by fax
• If any modifications are needed for pending or approved authorizations, providers will need to call Provider Services at 800-828-3407.
• Approvals issued before Jan. 1, 2026, are effective until the authorization end date.

Vendor Prior Authorization Requests

ConnectiCare has established a new vendor relationship with ProgenyHealth to conduct NICU utilization and care management services for our Marketplace members.

Optum Behavioral Health will continue to coordinate and manage behavioral health and substance abuse services for all our members.

Evolent (formerly known as New Century Health) will continue to conduct medical necessity reviews of medical oncology (including infusion medical oncology) in addition to radiation oncology for Marketplace and Medicare adult members ages 18 and over.

Beginning July 1, 2026, elective diagnostic and interventional cardiovascular services rendered in a physician’s office, ambulatory setting, outpatient hospital, or *inpatient hospital setting (*professional services only) will require authorization from Evolent. This authorization requirement applies to all provider specialties for ConnectiCare Medicare members 18 years of age and older.

Providers must contact these vendors directly for prior authorization requests for these services:

Pharmacy Prior Authorization Requests

CVS Caremark will support management of prescription drug benefits for our members. Prior authorization requests for pharmacy and HCPC/JCode can be submitted to ConnectiCare by phone, fax, or Electronic Prior Authorization platforms (Marketplace only):

ConnectiCare will be transitioning to Molina’s claims processing system:

• Molina performs SNIP Level 1–7 editing through our primary clearinghouse and internal EDI gateway before claims enter the core adjudication system.
• Claims missing required information or containing syntactical errors will be rejected via a 277CA electronic acknowledgment or a rejection letter for a paper claim.
• Electronic rejections enable quick correction and resubmission, often within the same day, resulting in faster and more accurate payment processing.

To ensure timely and accurate processing, all claims for Marketplace and Medicare members with dates of service (DOS) on or after Jan. 1, 2026, must be submitted using the new payer ID and mailing address noted below. These changes apply to both electronic and paper claims.

Payer ID

MLNCT

Electronic Submissions

• SSI Group: thessigroup.com directly or via any clearinghouse connected to SSI Group
• Availity Essentials portal for direct data entry: availity.com

Paper Submissions

ConnectiCare Claims
P.O. Box 36010
Louisville, KY 40233

Important Notes

• All claims for DOS before Jan. 1, 2026 must be submitted according to ConnectiCare’s current/existing claim submission process/payer IDs, and will be processed accordingly. If you submit a 2025 claim with the new payer ID, it will be rejected or denied.
• Commercial claims for 2026 DOS must be submitted according to ConnectiCare’s current/existing claim submission process and payer ID “06105.” If you submit a 2026 commercial claim with the new payer ID, it will be rejected or denied.
• Marketplace (Exchange) and Medicare claims for DOS starting Jan. 1, 2026 must be submitted electronically or by mail as instructed above with the new payer ID “MLNCT.”
• Do not combine professional claims with DOS before and after Jan. 1, 2026. These must be submitted as separate claims to avoid processing delays or denials. For inpatient facility claims, submit based on the admission date even if discharge is after Jan. 1, 2026.
• Freestanding ambulatory surgery centers will be required to submit facility charges claims on the CMS-1500 professional claim form for Medicare members in accordance with CMS billing guidelines.
• Providers must submit claims to ConnectiCare within 180 calendar days after the discharge for inpatient services or the date of service for outpatient services (unless otherwise specified by the applicable participation agreement or the member’s self-funded plan’s provisions).
• Providers must submit corrected claims to ConnectiCare within 100 additional days of the original submission timely filing limits of the claim.

Claim Dispute/Appeal Submissions

ConnectiCare claim dispute/appeal requests must be submitted 90 days (Marketplace) or 90 calendar days (Medicare) from the initial determination date unless otherwise specified in your Provider Agreement. Requests can be submitted via Availity Essentials portal, by fax, or mail:

Electronic Funds Transfer

ConnectiCare will continue our partnership with ECHO Health, Inc. (ECHO) for payment delivery and electronic remittance advice processing (EFT/ERA). To continue receiving EFT/ERA, you must enroll with ECHO for Molina with any recent ECHO Draft Number. Enrollment can be done now at enrollments.echohealthinc.com/efteradirect/molinahealthcare. If you need assistance, contact ECHO at:

Phone: 888-834-3511
Email: edi@echohealthinc.com

Effective Jan. 1, 2026, ConnectiCare will adopt Molina’s Clinical Policy, Reimbursement Policies, Pharmacy Policy Criteria, Marketplace Formulary, and Medicare Formulary for Marketplace and Medicare members.

ConnectiCare’s Payment Integrity Policies for Commercial members will not change at this point in time. In the future, if any policies are modified, ConnectiCare will notify providers.

Beginning November 2025, providers will receive, as applicable, credentialing and recredentialing communications directly from Molina on ConnectiCare’s behalf. Molina uses Council for Affordable Quality Healthcare (CAQH) for provider credentialing and recredentialing.  Providers need to maintain a CAQH profile, ensuring it’s up to date and authorized for ConnectiCare or Molina Healthcare Inc. if you have not opted for global authorization. 

If you’re adding a provider to your practice for credentialing on or after Jan. 1, 2026, you will begin the process with the Provider Network Pre-enrollment Portal. For instructions and additional information on how to submit a request to add a provider to your group, visit ConnectiCare’s Join Our Network page.

If your demographic information needs updating before or on/after Jan. 1, 2026, providers should submit through a roster profile and email the changes to 
CCI-ProviderFileOperations@MolinaHealthcare.com. Failure to do so will result in your removal from the ConnectiCare provider directory. A provider roster template can be provided, if needed.

All roster submissions must include all required information from the Molina roster template for successful processing. These requirements include, but are not limited to, group NPI number. Roster processing cannot be completed without all required data fields included. The approved template can be found in the Provider Network Management Portal under the Roster Upload tab.

Delegated providers should note; delegation oversight will be handled by Molina. You can expect to receive related communications directly from Molina on ConnectiCare’s behalf.

Beginning in December 2025, we will offer orientation and training webinars for providers. Look for announcements in the upcoming monthly provider newsletters.

• ConnectiCare Provider Orientation
• ProgenyHealth Provider Education and FAQ
• Prime Medical Pharmacy Program Overview

• 2026 Marketplace Provider Manual
• 2026 Medicare Provider Manual
• Clinical Policy
• Marketplace Prior Authorization List 
• Medicare Prior Authorization List 
• Prior Authorization LookUp Tool
• Payment Integrity Policies
• Reimbursement Policies
• Pharmacy Policy Criteria
• 2026 Marketplace Formulary 
• 2026 Medicare Formulary 
• Provider Online Directory
• Availity Essentials User Resources
• Frequently Asked Questions: Preliminary
• Frequently Asked Questions: Supplemental
• Quick Reference Guide
• 2026 Summary of Companies, Lines of Business, Networks & Benefit Plans
• Provider Notice of Changes
• Provider Newsletters
• Provider Bulletin Updates

Call Provider Services from 8 a.m. to 6 p.m., Monday through Friday at 800-828-3407.

Beginning Jan. 1, 2026, use the secure messaging feature in Availity Essentials to contact us.