2018 MNY PA Guide Request Form Medicaid/Essential Plan Revised June, 2018
/
/
1
Expedited/Urgent
DOB:
Phone:
/ / / / -
Contact
at
Requesting
Provider’s
Office*:
*Phone
Number:
Non-Participating/Non-Network
Provider
Name:
Provider
Address:
( ) -
( ) -
Molina
®
Healthcare – Medicaid/Essential Plan
Prior Authorization Request Form �
Utilization Management �
Phone: 1-877-872-4716 �
Fax: 1-866-879-4742 �
MEMBER INFORMATION
Plan:
Member Name:
Member
ID#:
Service
Type:
®
Molina Medicaid
Elective/Routine
Other:
( )
-
1
Definition
of
Expedited/Urgent
service
request
designation
is
when
the
treatment
requested is
required to prevent serious deterioration in the member’s health or
could
jeopardize the enrollee’s
ability to regain maximum function. Requests outside of
this
definition should be submitted as
routine/non-urgent.
REFERRAL/SERVICE
TYPE
REQUESTED
Outpatient
Inpatient
Surgical Procedure
Surgical procedures
DME
Diagnostic Procedure Hyperbaric Therapy
Admissions
Infusion Therapy Pain Management
SNF
Other:
LTAC
Diagnosis Code & Description: -
CPT/HCPC Code & Description: -
Number of visits requested: DOS From: to
Please send clinical notes and any supporting documentation �
PROVIDER INFORMATION
Requesting Provider Name _______________________________NPI#___________________TIN#____________
Servicing Provider or Facility: _____________________________NPI#___________________TIN#____________
___________________________________________________________
*Fax
Number:
___________________________Group
Name: _______________
__________________________________ Group Tax ID: _______________________________
City, State, Zip: ____________________________________ Medicaid
ID
(If Individual Provider):
__________________
Phone: ___________________________ Fax: _______________________ Provider NPI: ___________________
Group NPI:________________________
*For non-participating/non-network providers who do not complete this form, the form will be returned and may delay the determination for
requested services.
For Molina
®
Use Only:
Revised June, 2018
Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the
mem
ber’s eligibility, benefit limitation/exclusions,
- –
evidence of medical necessity and other applicable standards during the claim review.
