- Health Resources
- Utilization Management
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Molina’s UM Department is designed to provide comprehensive health care management by managing utilization services and benefits effectively and efficiently.
Molina follows a hierarchy of medical necessity decision-making, with federal and state regulations taking precedence. The following medical necessity criteria are used and available to contracted providers:
Providers can contact Molina at (855) 322-4082 to obtain criteria used to make a final determination.
Providers can contact us at our toll-free number (800) 869-7185 between 8 a.m. and 5 p.m. PST, Monday - Friday. We are available to discuss any utilization management requirements, processes or procedures.
In order to avoid the appeal process, providers can request a Peer-to-Peer discussion with a Molina Medical Director. The requesting provider has 10 business days for inpatient, or within 5 business days of discharge, and 10 business days of pre-service from receipt of the adverse benefit determination (denial) notification (verbal or fax notification), or any time before a decision is made, to schedule a Peer-to-Peer.If the Peer-to-Peer request is made more than 10 business days after the adverse benefit determination (denial) notification (or the member has discharged more than 5 business days from an inpatient facility):
Please call (425) 398-2603 to request and schedule a Peer-to-Peer discussion. Molina Medical Directors will be available to schedule a Peer-to-Peer Monday through Friday from 9 a.m. to 4 p.m. PST, excluding holidays. For Advance Imaging (AI) authorizations, please call (855) 714-2415 (option 1). A Molina Medical Director will call you at your scheduled date and time, at the direct number provided.When scheduling a Peer-to-Peer, you will be asked to provide:
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