Fillable MEDICAID/MARKETPLACE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE (Molina Healthcare)

Fill Online, Printable, Fillable, Blank MEDICAID/MARKETPLACE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE (Molina Healthcare) Form

Use Fill to complete blank online MOLINA HEALTHCARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MEDICAID/MARKETPLACE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE (Molina Healthcare)

On average this form takes 71 minutes to complete

The MEDICAID/MARKETPLACE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE (Molina Healthcare) form is 6 pages long and contains:

  • 0 signatures
  • 138 check-boxes
  • 219 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Molina Healthcare forms online.

BROWSE MOLINA HEALTHCARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Medicaid & Marketplace Guide
MOLINA HEALTHCARE
MEDICAID/MARKETPLACE PRIOR
AUTHORIZATION/PRE-SERVICE REVIEW GUIDE
EFFECTIVE: 10/1/21
REFER TO MOLINA’S PROVIDER WEBSITE OR PORTAL FOR SPECIFIC CODES THAT REQUIRE AUTHORIZATION ONLY COVERED
SERVICES ARE ELIGIBLE FOR REIMBURSEMENT
OFFICE VISITS OR REFERRALS TO IN NETWORK / PARTICIPATING PROVIDERS DO NOT REQUIRE PRIOR AUTHORIZATION
• Behavioral Health: Mental Health, Alcohol and Chemical
Dependency Services
• Cardiopulmonary Rehab: *Marketplace
Refer to Molina’s Provider website or portal for specific
codes that require authorization.
• Cosmetic, Plastic and Reconstructive Procedures
(in any setting)
• Durable Medical Equipment: Refer to Molina’s Provider
website or portal for specific codes that require
authorization.
• Experimental/Investigational Procedures
• Genetic Counseling and Testing
• Home Healthcare and Home Infusion (Including Home PT,
OT or ST): All home healthcare services require PA after initial
evaluation plus six (6) visits.
• Hyperbaric Therapy
• Imaging and Specialty Tests
• Inpatient Admissions: Acute hospital, Skilled Nursing
Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC)
Facility.
• Long Term Services and Supports: All LTSS services require
PA regardless of codes.
• Maternal Infant Health Program: Maternal beneficiaries are
only allowed up to nine (9) professional visits per
pregnancy. Infant beneficiaries are allowed up to nine
professional visits. With an accompanying physician order,
infant beneficiaries may receive an additional nine (9) visits
(for a total of 18). Providers should indicate they have a
physician order using the MDHHS 5650 Communication
Tool.
• Neuropsychological and Psychological Testing
• Non-Par Providers/Facilities: Office visits, procedures,
labs, diagnostic studies, inpatient stays except for:
Emergency Department Services;
Professional fees associated with ER visit and approved
Ambulatory Surgery Center (ASC) or inpatient stay;
Professional component services or services billed with
Modifier 26 in ANY place of service setting
Local Health Department (LHD) services;
Women’s Health, Family Planning and Obstetrical Services
Federally Qualified Health Center (FQHC) Rural Health Center
(RHC) or Tribal Health Center (THC)
• Occupational Therapy: After initial evaluation plus 36 visits
per calendar year for Medicaid. After initial evaluation plus
30 visits per calendar year (combined benefit with PT and
Chiropractic) for Marketplace.
• Outpatient Hospital/ASC Procedures: Refer to Molina’s
website or provider portal for a specific list of codes that
require PA.
• Pain Management Procedures: Refer to Molina’s website or
provider portal for a specific list of codes that require PA.
• Physical Therapy: After initial evaluation plus 36 visits per
calendar year for Medicaid. After initial evaluation plus 30
visits per calendar year (combined benefit with PT and
Chiropractic) for Marketplace.
• Prosthetics/Orthotics: Refer to Molina’s Provider website or
portal for specific codes that require authorization.
• Radiation Therapy and Radiosurgery
• Sleep Studies
• Specialty Pharmacy drugs: Refer to Molina’s Provider
website or portal for specific codes that require
authorization.
• Speech Therapy: After initial evaluation plus six (6) visits.
Pediatric cochlear implants – allowed up to 36 visits with
prior authorization for Medicaid. After initial evaluation plus
30 visits per calendar year for Marketplace.
• Transplants including Solid Organ and Bone Marrow (Cornea
transplant does not require authorization).
• Transportation: non-emergent Air Transport.
• Unlisted & Miscellaneous 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. Molina requires PA for all unlisted codes
except 90999 does not require PA.
• Urine Drug Testing: After 12 cumulative visits per calendar
year for Medicaid only. Please refer to Molina’s provider
website or portal for a specific list of codes that require PA.
⚬
⚬
⚬
⚬
⚬
⚬
Medicaid & Marketplace Guide
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 the enrollee’s 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 1 (855) 322-4077
MICHIGAN (Service hours 8:00am-5pm local M-F, unless otherwise specified)
Service Phone Fax
Authorizations (855) 322-4077 (800) 594-7404
Imaging Authorizations (855) 322-4077 (877) 731-7218
Transplant Authorizations (855) 714-2415 (877) 813-1206
Pharmacy Authorization (855) 322-4077 (888) 373-3059
Member Service (888) 898- 7969 TTY/TDD: 711
Provider Service (855) 322-4077 (248) 925-1784
Dental (800) 327-4462
Vision (VSP) (888) 493-4070
Transportation (855) 735-5604
24 Hour Nurse Advice Line (7 days/Week)
English 1 (888) 275-8750 / TTY: 1 (866) 735-2929
Spanish 1 (866) 648-3537 / TTY: 1 (866) 833-4703
SNF/LTAC/IPR Status Requests: Molina_SNF_LTAC_IPR@MolinaHealthCare.com
Denial Letter Requests: DenialLetterRequest@MolinaHealthCare.com
Medicaid & Marketplace Guide
Molina
Healthcare – Prior Authorization 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 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
DATES OF SERVICE DIAGNOSIS
CODES
PROCEDURE
CODES
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:
Medicaid & Marketplace Guide
Molina
Healthcare – BH Prior Authorization 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
REFERRAL/SERVICE TYPE REQUESTED
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:
PLEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION
Primary ICD-10 Code for Treatment: 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:
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:
Medicaid & Marketplace Guide
Alternative Level of Care Authorization Form
Phone: 866-449-6828
All Lines of Business Fax: (800) 594-7404
Patient Name: Molina ID: DOB/Age: Today’s Date:
Molina LOB: Medicare MMP / Duals Medicaid Marketplace
Level of Care Requested Based on InterQual: Inpatient Rehab
SNF Level 1 (1 discipline – 1-2 hrs/5 days/wk) LTACH
SNF Level 2 (4 hrs SN OR 1 discipline 2-3 hrs/5 days/wk) Custodial/Long term care
SNF Level 3 (IV abx, wound) (4 hrs SN AND 1 discipline 2-3 hrs/5 days/wk) (MMP only)
SNF Level 4 (vent/dialysis) Disenrollment request
Nursing Facility Requested: Hospital:
Tentative Admission Date: Hospital Admission Date:
Facility
Contact
Information:
CM/RN Name:
Hospital Contact
Information:
CM/RN Name:
CM/RN Phone: CM/RN Phone:
CM/RN Fax: CM/RN Fax:
Active Diagnosis (include ICD10 Codes): Most Recent Vital Signs:
BP: T:
P: SpO2:
R: Wt:
1.
2.
3.
Current Clinical Condition:
Past Medical/Surgical History: (Brief, related to current
condition):
Please indicate:
Smoker Alcohol/Substance Use DME
Living Arrangements:
Lives alone Lives with someone Homeless
Other:
Needs Help With:
Feeding Toileting Bathing Grooming Meal Preparation Other
Prior Level of Functioning before hospitalization:
Independent Contact Guard Supervised Wheelchair bound Other:
Participation Assistance Required while in SNF/IPR:
PT: Max Mod Min Contact Guard OT:
Max Mod Min Contact Guard ST:
Max Mod Min Contact Guard
Ambulation (Current): ft Goal: ft
Daily Participation Level while in hospital:
PT: hrs OR min
OT: hrs OR min
ST: hrs OR min
IV Medications that will continue post d/c (Must include start/date, dose, frequency):
Additional Comments:
**Therapy/Treatment Notes within 4 days of discharge must be included with this request
Medicaid & Marketplace Guide
Molina Healthcare
OB Notification Form
Phone Number: 1-888-898-7969
Fax Number: 844-861-1930 (Routine OB – NON - NICU)
Fax Number: 800-594-7404 (NICU)
*** 1 FORM PER NEWBORN ***
Mother’s Information
Plan
☐ Medicaid ☐ MiChild ☐ Medicare ☐ Marketplace
Mother’s Name:
Mother’s DOB / /
Mother’s ID #:
Mother’sPhone: ( ) -
Mother’s Admit Date: / / Mother’s Discharge Date / /
Service Type: NEWBORN NOTIFICATION
☐ NICU NICU Level ☐Border Baby
Hospital Referred to CSHCS? ☐Yes ☐No
Newborn Information
Newborn Name:
Newborn DOB / /
Newborn Admit Date / / Newborn Discharge Date / /
Newborn Admit Date: From / / TO: / /
Birth Order ☐1 ☐ 2 ☐ 3 ☐ 4 ☐5 ☐Other
Diagnosis Code & Description:
Delivery Date: / /
Delivery Type: ☐ Vaginal ☐ C-Section ☐ VBAC ☐ Repeat C-Section
Multiples?: ☐ No ☐ Yes Quantity
Baby’s Gender: ☐ Male ☐ Female
Baby’s Weight: lb oz
Apgar Score: /
EDD: / /
Gestation: wks
Birth Outcome:
☐ Discharge with Mom ☐ Border Baby ☐ Going to Foster Care
☐Adoption ☐Fetal Demise
Provider Information
Facility
Name
NPI
#:
TIN#:
Attending
Provider:
NPI
#:
TIN#:
Contact Information
Name:
Phone Number: ( ) - Fax Number: ( ) -
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MEDICAIDMARKETPLACE PRIOR AUTHORIZATIONPRE-SERVICE REVIEW GUIDE (Molina Healthcare)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document