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Molina Healthcare Of Ohio, Inc. – Prior Authorization Request Form

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Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc. – Prior Authorization Request Form
MEMBER INFORMATION
Line of
Business:
☐☐
eviCore
Fax: (800) 540-2406
☐☐
Medicaid
Fax: (866) 449-6843
☐☐
Marketplace
Fax: (833) 322-1061
☐☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
☐☐
MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
☐☐
MyCare Opt-Out
Fax: (866) 449-6843
☐☐
Transplant
All lines of business
Fax: (866) 449-6843
Medicare/D-SNP/
MyCare Opt-in
☐
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review &
discharge for hospital, SNF,
LTAC, Rehab, BH (excluding
Hospice room & board T2046)
☐ MyCare Opt-in
*Home Health &
Hospice room &
board T2046 only*
Fax: (877) 708-2116
Member Name:
Member ID#:
DOB:
Service
Type:
☐ Non-Urgent/Routine/Elective:
☐ Urgent/Expedited* – Clinical Reason for Urgency Required:____________________
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent.
☐
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☐
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☐
☐
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☐
☐
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☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
I
SERVICING PROVIDER/FACILITY:
Provider/Facility Name (Required):
NPI#:
TIN#:
Medicaid ID# (If Non-Par):
☐Non-Par ☐COC
Phone:
Fax:
Email:
25759FRMMDOHEN
M
EMBER
I
NFORMATION
Member
Name:
Date of Request: For MOLINA HEALTHCARE use only:
Member
ID#:
DOB:
Service Type:
☐
Non-Urgent/Routine/Elective:
☐ Urgent/Expedited
* Reason for Urgency _______________
☐ Emergent Inpatient
Admission
☐ EPSDT/Special
Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this denition should be submitted as routine/non-urgent.
FAX RESOURCES Per Line of Business/Service Type
(See Provider Website for Portal Information)
☐ Medicaid
Fax: (866) 449-6843
☐ Marketplace
Fax: (833) 322-1061
☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
Imaging and Special Tests:
o
Advanced Imaging (MRI, CT, PET, Selected ultrasounds)
o Cardiac Imaging
☐
All Lines of Business Fax: (877) 731-7218
☐☐ Transplant
(All lines of business)
Fax: (866) 449-6843
MyCare Opt-in
**Home Health & Hospice
room & board T2046 only
Fax: (877) 708-2116
☐
☐
☐ ☐
☐
Medicare/D-SNP
MyCare Opt-in
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review & discharge for
hospital, SNF, LTAC, Rehab, BH
(excluding Hospice room & board T2046)
Radiation Therapy
o Sleep Covered Services and Related Equipment
o Molecular & Genomic Tests
Medicaid & Marketplace:
Fax: (877) 731-7218
Medicare/D-SNP:
Fax: (844) 251-1450
MyCare Opt-in:
Fax: (844) 251-1451
MyCare Opt-Out
Fax: (866) 449-6843
☐ MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
Molina Healthcare of Ohio, Inc. – Prior Authorization Request Form
Request Type:
Initial Request Extension/Renewal/Amendment
Previous Auth#:
Inpatient Services: Outpatient Services:
Inpatient Hospital
Inpatient Transpl
ant
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
Primary ICD-10 Code: Description:
D
ATES OF SERVICE PROCEDURE/
S
ERVICE CODES
D
IAGNOSIS
CODE
R
EQUESTED SERVICE
R
EQUESTED
UNITS/VISITS
S
TART STOP
PROVIDER NFORMATION
REQUESTING PROVIDER/FACILITY:
Provider Name: NPI#:
Phone: Fax: Email:
Address: City: State: Zip:
PCP N
ame: PCP Phone:
Office Contact Name: Office Contact Phone:
REFERRAL/SERVICE TYPE REQUESTED
TIN#:
Molina Healthcare of Ohio, Inc.
MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc. – BH Prior Authorization Request Form
MEMBER INFORMATION
Line of
Business:
☐☐
eviCore
Fax: (800) 540-2406
☐☐
Medicaid
Fax: (866) 449-6843
☐☐
Marketplace
Fax: (833) 322-1061
☐☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
☐☐
MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
☐☐
MyCare Opt-Out
Fax: (866) 449-6843
☐☐
Transplant
All lines of business
Fax: (866) 449-6843
Medicare/D-SNP/
MyCare Opt-in
☐
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review &
discharge for hospital, SNF,
LTAC, Rehab, BH (excluding
Hospice room & board T2046)
☐ MyCare Opt-in
*Home Health &
Hospice room &
board T2046 only*
Fax: (877) 708-2116
Member Name:
Member ID#:
DOB:
Service
Type:
☐ Non-Urgent/Routine/Elective:
☐ Urgent/Expedited* – Clinical Reason for Urgency Required:____________________
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent.
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 (ACT)
☐ Targeted Case Management
☐ Institution of Mental Diseases (IMD)
☐ 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: Description:
DATES OF SERVICE
PROCEDURE/
S
ERVICE CODES
DIAGNOSIS
CODE
R
EQUESTED 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:
Address: City: State: Zip:
For Molina Healthcare Use Only:
PriorAuthorizationisnotaguaranteeofpaymentforservices.Paymentismadeinaccordancewithadeterminationofthemember’seligibilityonthedateof
service,benefitlimitations/exclusionsandotherapplicablestandardsduringtheclaimreview,includingthetermsofanyapplicableprovideragreement.
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc. – Prior Authorization Request Form
MEMBER INFORMATION
Line of
Business:
☐☐
eviCore
Fax: (800) 540-2406
☐☐
Medicaid
Fax: (866) 449-6843
☐☐
Marketplace
Fax: (833) 322-1061
☐☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
☐☐
MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
☐☐
MyCare Opt-Out
Fax: (866) 449-6843
☐☐
Transplant
All lines of business
Fax: (866) 449-6843
Medicare/D-SNP/
MyCare Opt-in
☐
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review &
discharge for hospital, SNF,
LTAC, Rehab, BH (excluding
Hospice room & board T2046)
☐ MyCare Opt-in
*Home Health &
Hospice room &
board T2046 only*
Fax: (877) 708-2116
Member Name:
Member ID#:
DOB:
Service
Type:
☐ Non-Urgent/Routine/Elective:
☐ Urgent/Expedited* – Clinical Reason for Urgency Required:____________________
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent.
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
PLEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION
Primary ICD-10 Code: Description:
DATES OF SERVICE
PROCEDURE/
S
ERVICE CODES
DIAGNOSIS
CODE
R
EQUESTED 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):
N
on-Par COC
Phone
: Fax: Email:
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Address:
City:
State:
Zip:
For Molina Healthcare 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 onthe date of
service, benefit limitations/exclusions andother applicable standards during the claim review, including the terms of any applicableprovider agreement.
Molina Healthcare of Ohio, Inc. – BH Prior Authorization Request Form
MEMBER INFORMATION
Line of
Business:
☐☐
eviCore
Fax: (800) 540-2406
☐☐
Medicaid
Fax: (866) 449-6843
☐☐
Marketplace
Fax: (833) 322-1061
☐☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
☐☐
MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
☐☐
MyCare Opt-Out
Fax: (866) 449-6843
☐☐
Transplant
All lines of business
Fax: (866) 449-6843
Medicare/D-SNP/
MyCare Opt-in
☐
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review &
discharge for hospital, SNF,
LTAC, Rehab, BH (excluding
Hospice room & board T2046)
☐ MyCare Opt-in
*Home Health &
Hospice room &
board T2046 only*
Fax: (877) 708-2116
Member Name:
Member ID#:
DOB:
Service
Type:
☐ Non-Urgent/Routine/Elective:
☐ Urgent/Expedited* – Clinical Reason for Urgency Required:____________________
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent.
☐
☐
☐
☐
☐
☐ ☐
☐
☐ ☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐ ________________________
PLEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION
Primary ICD-10 Code: Description:
DATES OF SERVICE
PROCEDURE/
S
ERVICE CODES
DIAGNOSIS
CODE
R
EQUESTED 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:
REFERRAL/SERVICE TYPE REQUESTED
Request Type:
Initial Request Extension/Renewal/Amendment
Previous Auth#:
Inpatie
nt Services: Outpatient Services:
Inpatient Psychiatric
Involuntary Voluntary
Inpati
ent Detoxification
Involuntary Voluntary
If Involuntary, Court Date:
Residential Treatment
Partial H
ospitalization Program
Intensive Outpatient Program
Day Treatment
Assertive Community Treatment Program (ACT)
Targeted Case Management
Institution of Mental Diseases (IMD)
Electroconvulsive Therapy
Psychological/Neuropsychological
Testing
Applied Behavioral Analysis
Non-PAR Outpatient Services
Other:
Molina Healthcare of Ohio, Inc.
MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
M
EMBER
I
NFORMATION
Member
Name:
Date of Request: For MOLINA HEALTHCARE use only:
Member
ID#:
DOB:
Service Type:
☐
Non-Urgent/Routine/Elective:
☐ Urgent/Expedited
* Reason for Urgency _______________
☐ Emergent Inpatient
Admission
☐ EPSDT/Special
Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this denition should be submitted as routine/non-urgent.
FAX RESOURCES Per Line of Business/Service Type
(See Provider Website for Portal Information)
☐ Medicaid
Fax: (866) 449-6843
☐ Marketplace
Fax: (833) 322-1061
☐ Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
Imaging and Special Tests:
o
Advanced Imaging (MRI, CT, PET, Selected ultrasounds)
o Cardiac Imaging
☐
All Lines of Business Fax: (877) 731-7218
☐ Transplant
(All lines of business)
Fax: (866) 449-6843
☐ MyCare Opt-in
**Home Health & Hospice
room & board T2046 only
Fax: (877) 708-2116
☐ Medicare/D-SNP
MyCare Opt-in
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review & discharge for
hospital, SNF, LTAC, Rehab, BH
(excluding Hospice room & board T2046)
Radiation Therapy
o Sleep Covered Services and Related Equipment
o Molecular & Genomic Tests
☐ Medicaid & Marketplace:
Fax: (877) 731-7218
☐ Medicare/D-SNP:
Fax: (844) 251-1450
☐ MyCare Opt-in:
Fax: (844) 251-1451
☐ MyCare Opt-Out
Fax: (866) 449-6843
☐ MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
Molina Healthcare of Ohio, Inc. – Prior Authorization Request Form
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
☐ ☐
PriorAuthorizationisnotaguaranteeofpaymentforservices.Paymentismadeinaccordancewithadeterminationofthemember’seligibilityonthedateof
service,benefitlimitations/exclusionsandotherapplicablestandardsduringtheclaimreview,includingthetermsofanyapplicableprovideragreement.
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Address:
City:
State:
Zip:
For Molina Healthcare 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 onthe date of
service, benefit limitations/exclusions andother applicable standards during the claim review, including the terms of any applicableprovider agreement.
Molina
Healthcare of Ohio, Inc. – BH Prior Authorization Request Form
MEMBER INFORMATION
Line of
Business:
☐☐
eviCore
Fax: (800) 540-2406
☐☐
Medicaid
Fax: (866) 449-6843
☐☐
Marketplace
Fax: (833) 322-1061
☐☐
Medicare/D-SNP
OUTPATIENT
Fax: (844) 251-1450
☐☐
MyCare Opt-In
OUTPATIENT
Fax: (844) 251-1451
(Excluding Home Health)
☐☐
MyCare Opt-Out
Fax: (866) 449-6843
☐☐
Transplant
All lines of business
Fax: (866) 449-6843
Medicare/D-SNP/
MyCare Opt-in
☐
INPATIENT
Fax: (844) 834-2152
Admit, Concurrent Review &
discharge for hospital, SNF,
LTAC, Rehab, BH (excluding
Hospice room & board T2046)
☐ MyCare Opt-in
*Home Health &
Hospice room &
board T2046 only*
Fax: (877) 708-2116
Member Name:
Member ID#:
DOB:
Service
Type:
☐ Non-Urgent/Routine/Elective:
☐ Urgent/Expedited* – Clinical Reason for Urgency Required:____________________
☐ Emergent Inpatient Admission
☐ EPSDT/Special Services
*The Expedited/Urgent 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 member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent.
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 (ACT)
☐ Targeted Case Management
☐ Institution of Mental Diseases (IMD)
☐ Electroconvulsive Therapy
☐ Psychological/Neuropsychological
Testing
☐ Applied Behavioral Analysis
☐ Non-PAR Outpatient Services
☐ Other: ________________________
SERVICING PROVIDER/FACILITY:
P
LEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION
Primary ICD-10 Code: Description:
D
ATES OF SERVICE PROCEDURE/
S
ERVICE CODES
DIAGNOSIS
CODE
R
EQUESTED SERVICE
REQUESTED
UNITS/VISITS
START STOP
PROVIDER INFORMATION
REQUESTING PROVIDER/FACILITY:
Provider Name: NPI#: TIN#:
Phone: Fax: Ema
il:
Address: City: State: Zi
p:
PCP Name: PCP Phone:
Office Contact Name: Office Contact Phone:
Provider/Facility Name (Required):
NPI#: Medicaid ID#
(If N
on-Par):
Non-Par COC
Phone
: Fax: Email:
Address: City: State: Zip:
For
Molina Healthcar
e Use Only:
Molina Healthcare of Ohio, Inc.
MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
MEDICAID, MEDICARE AND MYCARE OHIO
PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE
REFER TO MOLINA’S PROVIDER WEBSITE/PRIOR AUTHORIZATION LOOK-UP TOOL/MATRIX FOR
SPECIFIC CODES THAT REQUIRE A
UTHORIZATION
ONLY COVERED SERVICES ARE ELIGIBLE FOR REIMBURSEMENT
Behavioral Health, Mental Health and Alcohol
and Chemical Dependency Services:
o ACT
o IHBT
o CPST
o Psychological Testing
o SBIRT
o Alcohol or Drug Assessment
o Psychiatric Diagnostic Evaluations Inpatient, residential
t
reatme
nt, partial hospitalization
o Electroconvulsive therapy (ECT)
o Applied behavioral analysis (ABA)
Cosmetic, Plastic and Reconstructive
Procedures: No PA required with Breast Cancer
Diagnoses.
Dental general anesthesia: Greater than 7 years old
per state benefit (not a Medicare Covered Benefit)
Durable Medical Equipment and Medical
Supplies
: Refer to Molina Healthcare’s website or Web
Portal for specific codes that require authorization
o Medicare hearing supplemental benefit: contact Avesis
at (800) 327-4462
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 regulators
Healthcare Administered Drugs
o For Medicare Part B drug provider administered drug
therapies, please direct Prior Authorization requests to
Novologix via the Molina Provider Portal. You may also
fax in a prior authorization at (800) 391-6437.
Hearing Aids
o Benefit is only available from HearUSA participating
providers. Contact HearUSA at (855) 823-4632 to
schedule. Hearing aids require prior authorization.
Home Healthcare Services (including home-
based PT/OT/ST): Medicare/MMP Medicare: Prior
authorization required for any home healthcare in a year
beyond the initial 60 day period.
Marketplace/Medicaid/MMP Medicaid: after initial
evaluation plus 6 visits per calendar year.
Hyperbaric/Wound Therapy
Imaging and Special Tests
Inpatient Admissions/Inpatient Hospice and
Palliative care
Long Term Services and Supports (LTSS): Not a
Medicare covered benefit*. (*Per State benefit if MMP)
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 associated with ER visits and approved
Ambulatory Surgery Center (ASC) or inpatient stays
o Other services based on state requirements
Occupational, Physical, & Speech Therapy: PA
required after 30 visits
Outpatient Hospital/Ambulatory Surgery Center
(ASC) Procedures
: Refer to Molina Healthcare’s website
or Web Portal for specific codes that require authorization
Pain Management Procedures
Prosthetics/Orthotics: Refer to Molina Healthcare’s
website or Web Portal for specific codes that require
authorization
Pregnancy and delivery
Radiation Therapy and Radiosurgery
Respite care
Sleep Studies: Except Home (POS 12) sleep studies
Transplants/Gene Therapy, including Solid
Organ and Bone Marrow
(Cornea transplant does not
require authorization)
Transportation: Non-emergent air transportation
Wound Therapy
*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 claim. (Medicaid
benefit only.)
Refer to Molina Healthcare’s PA Code List for specific codes that require authorization at www.Moli
naHealthcare.com/OhioProviders
under the “Forms” tab.
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
▯
▯
▯
PRIOR AUTHORIZATION
Medicaid & MyCare Opt-Out
MyCare Opt-In Outpatient
(Excluding Home Health)
Phone: (855) 322-4079
Fax: (866) 449-6843
Phone: (855) 322-4079
Fax: (844) 251-1451
Transplant
(All lines of business)
MyCare Opt-In
(Home Health & Hospice Room and Board T2046)
Phone: (855) 322-4079
Fax: (866) 449-6843
Phone: (855) 322-4079
Fax: (877) 708-2116
Marketplace
Medicare/D-SNP Outpatient
Phone: (888) 333-8144
Fax: (833) 322-1061
Phone: (855) 322-4079
Fax: (844) 251-1450
eviCore Services
Medicare/D-SNP/MyCare Opt-In Inpatient
Phone: (888) 333-8144
Fax: (800) 540-2406
Phone: (855) 322-4079
Fax: (844) 834-2152
Pharmacy Authorizations
Medicaid Phone: (855) 322-4079
Fax: (800) 961-5160
Medicare Phone: (855) 322-4079
Fax: (866) 290-1309
Hearing (HearUSA)
Vision (March Vision Care)
Dental (SKYGEN)
Phone: (800) 442-8231
Monday to Friday,
8 a.m. to 8 p.m. EST
Phone: (844) 756-2724
TTY: 711
or (877) 627-2456
Phone: (888) 818-7932 TTY: 711
7 days a week,
8 a.m. to 8 p.m. EST
▅
▅
▅
PRIOR AUTHORIZATION
Medicaid & MyCare Opt-Out
MyCare Opt-In Outpatient
(Excluding Home Health)
Phone: (855) 322-4079 Fax: (866) 449-6843 Phone: (855) 322-4079 Fax: (844) 251-1451
Transplant
(All lines of business)
MyCare Opt-In
(Home Health & Hospice Room and Board T2046)
Phone: (855) 322-4079 Fax: (866) 449-6843 Phone: (855) 322-4079
IMPORTANT INFORMATION FOR MOLINA HEALTHCARE PROVIDERS
Information generally required to support authorization decision making includes:
• Current (up to 6 months) and 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
re
ason 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.
• Post-Stabilization Services: Effective 06/01/2014 — Molina Healthcare provides post-stabilization
services for Medicare members and MyCare Ohio dual eligible members.
If you are a non-contracted
provider and need authorization for post-stabilization services after normal business hours, please call our 24-
Hour Nurse Advice Line.
• Medicare – En
glish: (888) 275-8750 (TTY: 711)
• Medicare – Spanish: (866) 648-3537 (TTY: 711)
• MyCare Ohio/D-SNP English/Spanish: (855) 895-9986 (TTY: 711)
• Includes 24-Hour
Behavioral Health Crisis Line
IMPORTANT MOLINA HEALTHCARE CONTACT INFORMATION
OHIO (Service hours 8 a.m.to 5 p.m. local time, Monday through Friday, unless otherwise specified)
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 fre
quently used forms
• Provider Directory Nurse Advice Line
Fax: (877) 708-2116
Marketplace Medicare/D-SNP Outpatient
Phone: (855) 322-4079 Fax: (833) 322-1061 Phone: (855) 322-4079 Fax: (844) 251-1450
Imaging and Special Tests
Medicare/D-SNP/MyCare Opt-In Inpatient
Phone: (855) 322-4079 Fax: (877) 731-7218 Phone: (855) 322-4079 Fax: (844) 834-2152
Medicaid & Marketplace Radiation Therapy Medicare/D-SNP Radiation Therapy
Phone: (855) 322-4079 Fax: (877) 731-7218 Phone: (855) 322-4079 Fax: (844) 251-1450
MyCare Opt-In Radiation Therapy
Phone: (855) 322-4079 Fax: (844) 251-1451
Molina Healthcare of Ohio, Inc. MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Molina Healthcare of Ohio, Inc.
MHO-0709 Ohio PA Guide/Request Form
Effective 05/01/2021
Pharmacy Authorizations
Medicaid Phone: (855) 322-4079 Fax: (800) 961-5160 Medicare Phone: (855) 322-4079 Fax: (866) 290-1309
Hearing (HearUSA) Vision (March Vision Care) Dental (SKYGEN)
Phone: (800) 442-8231
Monday to Friday,
8 a.m. to 8 p.m. EST
Phone: (844) 756-2724
TTY: 711
or (877) 627-2456
Phone: (888) 818-7932 TTY: 711
7 days a week,
8 a.m. to 8 p.m. EST
IMPORTANT MOLINA HEALTHCARE CONTACT INFORMATION
24-Hour Nurse Advice Line (24 hours a day, 7 days a week)
Medicaid/Medicare/Marketplace
24-Hour Nurse Advice Line (24 hours a day, 7 days a week)
MyCare Ohio
No referral or prior
authorization is needed.
English:
(888) 275-8750
TTY: 711
Spanish:
(866) 648-3537
TTY: 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.
English & Spanish:
(855) 895-9986
TTY: 711
Provider Services
Phone:
(855) 322-4079
Fax:
(888) 296-7851
MyCare Ohio/D-SNP:
8 a.m. to 6 p.m.
All other lines of
business:
8 a.m. to 5 p.m.
Meals
(Mom’s Meals NourishCare PurFoods, LLC dba)
Care Manager must enroll the member in the
home delivered meal program giving them
access to this benefit.
Care Managers Phone:
(866) 224-9485
MEMBER SERVICE CONTACT INFORMATION
Medicaid Medicare
MyCare Ohio
Opt-In
MyCar
e Ohio
Opt-Out
Marketplace
7 a.m. to 7 p.m.
Monday to Fri
day
(800) 642-4168
TTY: 711
8 a.m. to 8 p.m.
7 days a week
(866) 472-4584
TTY:711
8 a.m. to 8 p.m.
Monday to Friday
(855) 665-4623
TTY: 71
1
8 a.m. to 8 p.m.
Monday to Fri
day
(855) 687-7862
TTY: 711
8 a.m. to 6 p.m.
Monday to Friday
(888) 296-7677
TTY: 711
Transportation
(Access2Care (A2C)
Where needed,
authorizations are not
required unless over the
trip limit (over 50 miles
one-way).
MyCare Ohio: (844) 491-4761
Medicaid: (866) 642-9279
Press 1 for Ride Assist; otherwise stay on the line for
assistance.
Monday to Friday:
8 a.m. to
8 p.m. local time for ROUTINE reservations.
Requests for ROUTINE reservations will not be accepted on
national holidays. This does not apply to URGENT same day
appointments, facility DISCHARGES, and RIDE ASSIST – these
calls are 24 hours a day, 7 days a week, 365 days a year.
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Molina Healthcare Of Ohio, Inc. Prior Authorization Request Form

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Completed 12 October 2021

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