Molina Healthcare's Utilization Management

One of the goals of Molina Healthcare Utilization Management (UM) department is to render appropriate UM decisions that are consistent with objective clinical evidence. To achieve that goal, Molina Healthcare maintains the following guidelines:

Appropriate Professionals

  • Medical information received by our providers is evaluated by our highly trained UM staff against nationally recognized objective and evidence-based criteria. We also take individual circumstances and the local delivery system into account when determining the medical appropriateness of requested health care services. All denials of requested services are rendered by a medical reviewer who is either a physician or pharmacist (for medication requests).

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Criteria

  • Molina Healthcare's clinical criteria includes McKesson InterQual® criteria, Hayes Directory, Medicare National and Local Coverage Determinations, applicable Medicaid Guidelines, Molina Healthcare Medical Coverage Guidance Documents (developed by designated Corporate Medical Affairs staff in conjunction with Molina Healthcare physicians serving on the Medical Coverage Guidance Committee) and when appropriate, third party (outside) board-certified physician reviewers.
  • Molina Healthcare ensures that all criteria used for UM decision-making are available to providers upon request. To obtain a copy of the UM criteria used in the decision-making process, call our UM department at (888) 999-2404.

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How to Contact UM Staff and Medical Reviewer

  • Molina Healthcare UM staff is always available to receive your calls and provide outbound communication regarding UM issues. You may call (888) 999-2404 during normal business hours Monday through Friday 8:00 AM to 5:00 PM (CST). After our normal business hours, you may contact our Nurse Advice Line (888) 275-8750 for assistance.
  • As the requesting provider, you will receive written notification of all UM denial decisions. The notification will include the name and telephone number of the Molina Healthcare physician that made the decision. Please feel free to call him or her to discuss the case. If you need assistance contacting a medical reviewer about a case please call the UM Department at (888) 999-2404.

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Affirmative Statement

It is important to remember that:

1. UM decision making is based only on appropriateness of care and service and existence of coverage.
2. Molina Healthcare does not specifically reward providers or other individuals for issuing denials of coverage or care.
3. UM decision makers do not receive incentives to encourage decisions that result in underutilization.
 
To determine if prior authorization is required for a service, please see the Provider Manual for more information.

 

New Technology

Molina Healthcare evaluates the appropriate use of new developments in technology and the application of existing technologies relating to medical and behavioral procedures, equipment, devices and pharmaceuticals for inclusion into Molina Healthcare benefit plan decision making processes. This process allows Molina Healthcare to:

  • Keep abreast of ongoing changes in technology
  • Provide access to obtain safe and effective care
  • Review information from appropriate governmental regulatory bodies and from published scientific evidence
  • Obtain input from specialists and professionals with unique knowledge about the specific technology reviewed
  • Outline the variables used in making determinations including, but not limited to, experimental and investigational procedures
  • Review the criteria and procedures for applying them annually and update the criteria when appropriate

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* Printed copies of information posted on our website are available upon request.