Molinalogo

We use evidence-based clinical practice guidelines when making decision about members’ care.

Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.

When determining the medical appropriateness of a service, we apply these criteria while taking into account individual circumstances and the local delivery system.

Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage underutilization by providing financial incentives to deny coverage.

View our Clinical Practice Guidelines 

Notwithstanding any provision in the Provider Agreement that requires Provider to obtain a prior authorization directly from Molina, Molina may choose to contract with external vendors to help manage prior authorization requests.

For additional information regarding the prior authorization of specialized clinical services, please refer to the prior authorization tools:

• Prior Authorization Code Look-up Tool
• Prior Authorization Code Matrix
• Prior Authorization Guide
  
  

Availity Essentials portal:Participating Providers are encouraged to use the Availity Essentials portal for prior authorization submissions whenever possible. Instructions for how to submit a prior authorization request are available on the Availity Essentials portal. The benefits of submitting your prior authorization request through the Availity Essentials portal are:

• Create and submit Prior Authorization Requests.
• Check status of Authorization Requests.
• Receive notification of change in status of Authorization Requests.
• Attach medical documentation required for timely medical review and decision making.
  
  

Fax: The Prior Authorization Request Form can be faxed to Molina at: (833) 832-1015.

Phone: Prior authorizations can be initiated by contacting Molina’s Healthcare Services department at (844) 782-2678. It may be necessary to submit additional documentation before the authorization can be processed.

Molina Healthcare Member Services is available to help our members if they have any questions about their benefits and services.

• Member services staff are available Monday through Friday from 8 a.m. to 6 p.m. local time.

 

Holiday Schedule - The Molina Healthcare office is closed on the following days:




New Years Day (we will be open on 1/1/2024 as it is the launch date for our new membership, but will be closed going forward on New Year’s Day).




Martin Luther King Jr. Birthday
Memorial Day Independence Day
Labor Day
Thanksgiving Day
Thanksgiving Friday
Christmas Day


Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.

• Molina Healthcare offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are Molina Healthcare members and offer them appropriate assistance.

If members receive care from out-of-network providers without prior authorization, Molina Healthcare will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives a Molina Healthcare member emergency care, the service will be paid.

Visit our Forms page for the most up-to-date list of services requiring prior authorization. Refer to the Molina Healthcare provider manual  for more information about prior authorization.