Fillable Form .11: PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE MOLINA EFFECTIVE: (Molina Healthcare)

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Form .11: PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE MOLINA EFFECTIVE: (Molina Healthcare)

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MOLINA
®
HEALTHCARE MEDICAID
PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE
EFFECTIVE: 01/01/2022
Molina Healthcare, Inc. Q1 2021 Medicaid PA Guide/Request Form
Effective 01.01.2021
REFER TO MOLINA’S PROVIDER WEBSITE OR PRIOR AUTHORIZATION LOOK-UP TOOL/MATRIX FOR
SPECIFIC CODES THAT REQUIRE AUTHORIZATION
ONLY COVERED SERVICES ARE ELIGIBLE FOR REIMBURSEMENT
OFFICE VISITS TO CONTRACTED/PARTICIPATING (PAR) PROVIDERS & REFERRALS TO NETWORK SPECIALISTS DO NOT
REQUIRE PRIOR AUTHORIZATION.
EMERGENCY SERVICES DO NOT REQUIRE PRIOR AUTHORIZATION.
Advanced Imaging and Special Tests
Behavioral Health: Mental Health, Alcohol and
Chemical Dependency Services:
o Inpatient, Residential Treatment,
Partial Hospitalization, Day Treatment
o Intensive Outpatient beyond 16 units
o Electroconvulsive Therapy (ECT)
o Applied Behavioral Analysis (ABA) – for treatment of
Autism Spectrum Disorder (ASD)
Cosmetic, Plastic and Reconstructive
Procedures: No PA required with Breast Cancer
Diagnoses
Durable Medical Equipment
Elective Inpatient Admissions: Acute Hospital,
Skilled Nursing Facilities (SNF), Acute Inpatient
Rehabilitation, Long Term Acute Care (LTAC)
Facilities
Experimental/Investigational Procedures
Genetic Counseling and Testing (Except for
prenatal diagnosis of congenital disorders of the
unborn child through amniocentesis and genetic test
screening of newborns mandated by state
regulations)
Healthcare Administered Drugs
Home Healthcare Services (including home-
based PT/OT/ST required after evaluation and
initial 6 visits)
Hyperbaric/Wound Therapy
Long Term Services & Support (Per State
benefit): All LTSS services require PA regardless of
code(s).
Miscellaneous & Unlisted Codes: Molina requires
standard codes when requesting authorization.
Should an unlisted or miscellaneous code be
requested, medical necessity documentation and
rationale must be submitted with the prior
authorization request.
Neuropsychological and Psychological Testing
Non-Par Providers/Facilities: PA is required for office
visits, procedures, labs, diagnostic studies, and inpatient stays
except for:
o Emergency and Urgently Needed Services;
o Professional fees for Medicaid enrolled providers associated
with ER visits and approved Ambulatory Surgery Center
(ASC) or inpatient stays;
o Local Health Department (LHD) services;
o Radiologists, anesthesiologists, and pathologists
professional services when billed in POS 19, 21, 22, 23 or
24;
o PA is waived for professional component services or
services billed from Medicaid enrolled providers with
Modifier 26 in ANY place of service setting;
o Other State mandated services.
Nursing Home/Long Term Care
Occupational, Physical & Speech Therapy
Outpatient Hospital/Ambulatory Surgery Center
(ASC) Procedures
Pain Management Procedures
Prosthetics/Orthotics
Radiation Therapy and Radiosurgery
Sleep Studies
Transplants/Gene Therapy, including Kidney,
Liver and Bone Marrow: (Cornea transplant does not
require authorization)
Transportation Services: Non-emergent air
transportation requires authorization (see below for
contact information for non-emergency transportation)
STERILIZATION NOTE: Federal guidelines require that at least 30 days have passed between the date of
the individual’s signature on the consent form and the date the sterilization was performed. The consent
form must be submitted with the claim.
••
•
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Molina Healthcare, Inc. Q1 2022 Medicaid PA Guide/Request Form
Effective 01.01.2022
IMPORTANT INFORMATION FOR MOLINA HEALTHCARE MEDICAID PROVIDERS
Information generally required to support authorization decision making includes:
• Current (up to 6 months), adequate patient history related to the requested services.
• Relevant physical examination that addresses the problem.
• Relevant lab or radiology results to support the request (including previous MRI, CT, Lab or X-ray report/results).
• Relevant specialty consultation notes.
• Any other information or data specific to the request.
The Urgent / Expedited service request designation should only be used if the treatment is required to
prevent serious deterioration in the member’s health or could jeopardize their ability to regain maximum
function. Requests outside of this definition will be handled as routine / non-urgent.
• If a request for services is denied, the requesting provider and the member will receive a letter explaining the
reason for the denial and additional information regarding the grievance and appeals process. Denials also are
communicated to the provider by telephone, fax or electronic notification. Verbal, fax, or electronic denials are
given within one business day of making the denial decision or sooner if required by the member’s condition.
• Providers and members can request a copy of the criteria used to review requests for medical services.
• Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions with the
requesting physician at (833) 685-2103.
Important Molina Healthcare Medicaid Contact Information
(Service hours 8am-5pm local M-F, unless otherwise specified)
Prior Authorizations including Behavioral
Health Authorizations:
Phone: (833) 685-2103
Fax: (775) 460-4900
24 Hour Behavioral Health Crisis (7 days/week):
Phone: (833) 685-2102 / TTY/TDD: 711
Pharmacy Authorizations:
Phone: (833) 685-2103
Fax: (844) 259-1689
Radiology Authorizations:
Phone: (855) 714-2415
Fax: (877) 731-7218
Vision: (VSP)
Phone: (833) 685-2102
Website: VSP.com
Provider Customer Service:
Phone: (833) 685-2103
Member Customer Service, Benefits/Eligibility:
Phone: (833) 685-2102/ TTY/TDD 711
Non-Emergency Transportation:
Phone: (844) 879-7341 or
(833) 685-2102 / TTY/TDD: 711
24 Hour Nurse Advice Line (7 days/week)
Phone: (833) 685-2104 / TTY/TDD: 711
Members who speak Spanish can press 1 at the IVR prompt. The
nurse will arrange for an interpreter, as needed, for non-
English/Spanish speaking members.
No referral or prior authorization is needed.
Transplant Authorizations:
Phone: (855) 714-2415
Fax: (877) 813-1206
Providers may utilize Molina Healthcare’s Website at: https://provider.molinahealthcare.com/Provider/Login
Available features include:
• Authorization submission and status Claims submission and status
• Member Eligibility Download Frequently used form
• Provider Directory Nurse Advice Line Report
••
•111MOLINA
I H EA L
HICA
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Molina Healthcare, Inc. Q1 2022 Medicaid PA Guide/Request Form
Effective 01.01.2022
Molina® Healthcare, Inc. – Prior Authorization Service Request Form
MEMBER INFORMATION
Line of Business:
☐
Medicaid
☐
Marketplace
☐
Medicare
Date of Request:
State/Health Plan (i.e. CA):
Member Name:
DOB (MM/DD/YYYY):
Member ID#:
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
:
PLEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION
Primary ICD-10 Code: Description:
DATES OF SERVICE 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:
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.
Molina Healthcare, Inc. Q1 2022 Medicaid PA Guide/Request Form
Effective 01.01.2022
Molina® Healthcare, Inc. – BH Prior Authorization Service Request Form
Line of Business:
☐ Medicaid
☐ Marketplace
☐ Medicare
Date of Request:
State/Health Plan (i.e. CA):
Member Name:
DOB (MM/DD/YYYY):
Member ID#:
Member Phone:
Service Type:
☐ Non-Urgent/Routine/Elective
☐ Urgent/Expedited – Clinical Reason for Urgency Required:
☐ Emergent Inpatient Admission
Request Type:
☐ Initial Request
☐ Extension/ Renewal / Amendment
Previous Auth#:
Inpatient Services:
Outpatient Services:
☐ Inpatient Psychiatric
☐Involuntary ☐Voluntary
☐ Inpatient Detoxification
☐Involuntary ☐Voluntary
If Involuntary, Court Date: __________
☐ Residential Treatment
☐ Partial Hospitalization Program
☐ Intensive Outpatient Program
☐ Day Treatment
☐ Assertive Community Treatment Program
☐ Targeted Case Management
☐ Electroconvulsive Therapy
☐ Psychological/Neuropsychological Testing
☐ Applied Behavioral Analysis
☐ Non-PAR Outpatient Services
☐ Other:
DATES OF SERVICE
PROCEDURE/
SERVICE CODES
DIAGNOSIS
CODE
REQUESTED SERVICE
REQUESTED
UNITS/VISITS
START
STOP
Provider Name:
NPI#:
TIN#:
Phone:
FAX:
Email:
Address:
City:
State:
Zip:
PCP Name:
PCP Phone:
Office Contact Name:
Office Contact Phone:
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
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Completed 7 March 2022

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