Fillable Molina Medicaid Molina Dual Options (Medicaid/Medicare) (Molina Healthcare)

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Molina Medicaid Molina Dual Options (Medicaid/Medicare) (Molina Healthcare)

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MMP/Medicaid
Phone:
(855) 866-5462
Medicaid
Fax:
(866) 617-4971
MMP - Inpatient
Fax: (844) 834-2152
MMP - Outpatient
Fax: (844) 251-1451
Non-Emergent
Transportation:
MTM Phone:
(844) 644-6354
MTM: Fax
(877) 406-0658
Imaging &
Special
Testing:
Fax:
(877) 731-7218
NICU Fax:
(866) 617-4971
Transplant Fax:
(877) 813-1206
Member Information
Plan:
□ Molina Medicaid □ Molina Dual Options (Medicaid/Medicare)
Member Name:
DOB: Today’s Date:
Member ID:
Member Phone Number:
Service Type: Elective/Routine
Determination within four (4) calendar days
from receipt of all necessary information.
Expedited/Urgent
I certify the request is urgent and medically necessary to treat an injury,
illness or condition (not life-threatening) within 48 hours to avoid
complications and unnecessary suffering or severe pain.
*** Clinical notes and supporting documentation are REQUIRED to review for medical necessity.***
* PA not required. Please notify Molina upon admission.
Referral/Service Type Requested
Repeat request/PA expired
Previous Authorization No.:
Inpatient:
ER Admits
SNF LTAC
Custodial
Acute Inpatient Rehab
Inpatient Detox
Ventilator Services
**Outpatient:
Surgical Procedure
Diagnostic Procedure
Infusion Therapy
Speech Therapy
Physical Therapy
Occupational Therapy
**Office:
Office Procedure/Visit
** DME
Wheelchair (Purchase/Repair)
Enteral Formula/Supplies
Prosthetic/Orthotic
Other
Out-of-State request
** Home Health:
Skilled Services
Home Infusion
Procedure Information
*Diagnosis Code & Description:
For Molina Healthcare use only:
*CPT/HCPC Code & Description:
*J Code/Description/Dose/NDC:
*Number of visits/days/units requested (circle type and specify quantity):
Dates of Service: From: To:
Requesting Provider Information
*Name/Credentials: IL Medicaid Certified
□ Yes
□ No
*Address: Contact Name:
*Billing NPI: *Phone No.: (
)
*Fax No.: ( )
*Billing TIN:
Servicing Provider / Facility Information
*Name: IL Medicaid Certified
□ Yes □ No
*Address: Contact Name:
*
Servicing NPI:
*Phone No.: (
)
*Fax No.: ( )
*
Servicing TIN:
*ALL REQUIRED FIELDS—MUST BE COMPLETED. INCOMPLETE FORMS WILL BE REJECTED.
Molina Healthcare of Illinois Medical Prior Authorization
Request Form
For Medicaid and MMP/Dual Options Plans
Radiation, Sleep,
Molecular Tests:
Medicaid Fax:
(877) 731-7218
MMP Fax:
(844) 251-1451
***PA NOT REQUIRED FOR PLANNED ADMISSIONS. PLEASE NOTIFY MOLINA UPON ADMISSION.***
Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be
a covered Health Plan Benefit and medically necessary with prior authorization as per plan policy and procedures.
Confidentiality: The information contained in the transmission is confidential and may be protected under the Health Insurance
Portability and Accountability Act of 1996. If you are not the intended recipient any use, distribution, or copying is strictly prohibited. If
you have received this facsimile in error, please notify us immediately and destroy this document.
By requesting prior authorization, the provider is affirming that the services are medically necessary; a covered benefit under the Medicare
and/or Medicaid Program(s), and the servicing provider is enrolled in those programs as eligible for reimbursement. As a condition of
authorization, for services that are primary to Medicare, the out-of-network provider agrees to accept no more than 100 percent of an
amount equivalent to the Medicare Fee-For-Service Program allowable payment rates (adjusted for place of service or geography) set forth
by CMS in effect on the Date(s) of Service, and any portion, if any, that the Medicaid agency or Medicaid managed care plan would have
been responsible for paying if the Member was enrolled in the Medicare Fee-For-Service Program. The Medicare Fee-For-Service Program
allowable payment rate deducts any cost sharing amounts, including but not limited to co -payments, deductibles, co-insurance, or amounts
paid or to be paid by other liable third parties that would have been deducted if the Member was enrolled in the Medicare Fee-For-Service
Program. If the service is primary to Medicaid, the out-of-network agrees to accept no more than the amount equivalent to the Medicaid
Fee-For-Service Program allowable payment rates set forth by the State of Illinois in effect on the Date(s) of Service, less any applicable
Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third parties, if any. Molina Healthcare will
not reimburse providers for services that are not deemed medically necessary. Servicing providers also recognize that Molina Healthcare
members are not to be balanced billed for any uncollected monies for covered services pursuant to Medicare and Medicaid billing
guidelines.
Effective 01/11/2022
© 2022 Molina Healthcare of Illinois, Inc.
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Molina Medicaid Molina Dual Options (MedicaidMedicare) (Molina Healthcare)

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Completed 26 February 2022

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