Molina® Healthcare, Inc. – Prior Authorization Service Request Form
EFFECTIVE: 01/01/2021
FAX (866) 423-3889 PHONE (855) 237-6178
Molina Healthcare of South Carolina, Inc. 2021 Prior Authorization Guide/Request Form
Effective 01.01.21
MEMBER INFORMATION
Line of Business:
☐
Medicaid
☐
Marketplace
☐
Medicare
Date of Request:
DOB (MM/DD/YYYY):
Member Phone:
Service Type:
☐ Non-Urgent/Routine/Elective
☐ Urgent/Expedited – Clinical Reason for Urgency Required:
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
REFERRAL/SERVICE TYPE REQUESTED
Request Type:
☐
Initial Request
☐
Extension/ Renewal / Amendment
Previous Auth#:
Inpatient Services: Outpatient Services:
☐ Inpatient Hospital
☐ Inpatient Transplant
☐ Inpatient Hospice
☐ Long Term Acute Care (LTAC)
☐ Acute Inpatient Rehabilitation (AIR)
☐ Skilled Nursing Facility (SNF)
☐ Other Inpatient:
☐ Chiropractic
☐ Dialysis
☐ DME
☐ Genetic/Genomic Testing
☐ Home Health
☐ Hospice
☐ Hyperbaric Therapy
☐ Imaging/Special Tests
☐ Office Procedures
☐ Infusion Therapy
☐ Laboratory Services
☐ LTSS Services
☐ Occupational Therapy
☐ Outpatient Surgical/Procedures
☐ Pain Management
☐ Palliative Care
☐ Pharmacy
☐ Physical Therapy
☐ Radiation Therapy
☐ Speech Therapy
☐ Transplant/Gene Therapy
☐ Transportation
☐ Wound Care
☐ Other:
Primary ICD-10 Code: Description:
ATES OF
ERVICE
PROCEDURE/
SERVICE CODES
DIAGNOSIS CODE REQUESTED SERVICE
REQUESTED
UNITS/VISITS
START STOP
PROVIDER INFORMATION
REQUESTING PROVIDER / FACILITY:
Provider Name: NPI#: TIN#:
Phone: FAX: Email:
Address: City: State: Zip:
PCP Name: PCP Phone:
Office Contact Name: Office Contact Phone:
SERVICING PROVIDER / FACILITY:
Provider/Facility Name (Required):
NPI#: TIN#:
Medicaid ID# (If Non-Par):
☐Non-Par ☐COC
Phone: FAX: Email:
Address: City: State: Zip:
For Molina Use Only:
Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member’s eligibility, benefit
limitation/exclusions, evidence of medical necessity and other applicable standards during the claim review.
J Code Drug Requests (Include J Code, Drug Name, Dosage, and Frequency)
J Code: Drug Name: Dosage: Frequency:
J Code: Drug Name: Dosage: Frequency:
J Code: Drug Name: Dosage: Frequency:
J Code: Drug Name: Dosage: Frequency:
Please send clinical notes and any supporting documentation
