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Medical Necessity Criteria

Information sources used to determine benefit coverage and medical necessity include AHCCCS state coverage policies (AMPM/ACOM), MCG, Molina proprietary guidelines, national practice guidelines, evidence-based guidelines, expert board-certified consultant advisors, enrollee-specific information gathered during care management including behavioral and physical health history, social needs, information from family members as well as specific treatment information from providers. The criterion used is designed to assist clinicians and providers in recognizing the most effective health care practices used today which ensures quality of care to our members. This criterion is not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about their patient’s health care needs. Molina Complete Care (MCC) utilizes MCG and ASAM nationally established and recognized criteria to determine medical necessity and appropriateness of care. The criterion used is designed to assist clinicians and providers in recognizing the most effective health care practices used today which ensures quality of care to our members. Criteria are reviewed at least annually with input from network providers and updated as necessary.

If a member’s clinical documentation doesn’t meet the criteria, the case is forwarded to a medical director for further review and determination. The medical directors are available to discuss individual cases with attending physicians upon request.

Upon request, MCC will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling (800) 424-5891 or faxing the utilization management department at (888) 656-7501. If you would like to discuss an adverse decision with the MCC medical director, please call the utilization management department within five business days of the determination.

Authorizations are not a guarantee of payment, but are based on medical necessity review, appropriate coding and benefits. Benefits may be subject to qualifications and/or limitation and will be determined when the claim is received for processing. Payment is contingent upon the eligibility of the member at the time of service.

Please note that a member ID card is not a guarantee of payment for services rendered. The provider’s office is responsible for verifying eligibility at the time of each office visit.

Utilization Management (UM)

The purpose of the Molina Complete Care (MCC)’s utilization management program is to support optimal use of health care services and supports for the evaluation, treatment and integration of medical, dental and behavioral health conditions. The MCC utilization management and care management teams collaborate to ensure seamless, timely and accurate care and service authorization processes.

The utilization management department performs many functions including concurrent review, prior authorization, discharge planning assistance, retrospective review and other activities. Our utilization management program has the goal of optimizing the use of healthcare resources for our members. Services provided are not less than the amount, duration and scope for the same services delivered to fee for service AHCCCS Medicaid members. Medically necessary services are no more restrictive than used in the AHCCCS defined program. MCC makes the utilization management criteria available in writing, by mail, or fax. MCC supports continuity and coordination of care for physical, dental and behavioral health providers. Our members’ health is always our number one concern.

Utilization review determinations are based only on appropriateness of care, service and benefit coverage. MCC does not reward providers or any staff members for adverse decisions for coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in under-utilization. An authorization does not replace the provider’s judgment with respect to the member’s condition or treatment requirements.

MCC providers can call our toll-free number at (800) 424-5891 with any utilization management questions 24 hours a day, 7 days a week.

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Prior Authorizations

Prior authorizations can be requested from the MCC utilization management department. Providers are expected to submit a pre-service authorization request prior to providing the service or care. Any services that require an authorization and have been delivered before an approval is given by MCC will be denied for payment. When submitting a prior authorization request, please include all supporting documentation. Unplanned admission notification to an inpatient facility is required within one business day of admission.