Molina’s UM Department is designed to provide comprehensive health care management by managing utilization services and benefits effectively and efficiently.
UM Decision Making
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:
- Applicable federal or state mandates and guidelines as required
- American Society of Addiction Medicine (ASAM)
- Molina WA Merge Criteria - Molina Medicaid prior authorization (PA) criteria which includes Health Care Authority (HCA) guidance on certain procedures
- Molina WA Pharmacy Criteria - Policies and guidelines intended to be a resource for relevant information about drugs, treatment and coverage
- Molina Clinical Policy (MCP) - Corporate guidance documents addressing new or existing technology
- MCG care guidelines (secure provider portal)
Providers can contact Molina at (855) 322-4082 to obtain criteria used to make a final determination.
Helpful Web Addresses
Contact Utilization Staff
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.
Peer-to-Peer Discussion and Reconsideration Process
For Medicaid or Marketplace members:
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.
- May be requested within 3 business days from adverse benefit determination (denial) notification (written or fax notification), or at any time during an inpatient admission
- Please use the reconsideration process first for denials when no clinical information was provided. This may result in an approval or a revised denial that would come with new Peer-to-Peer and reconsideration timeframes
- May not be requested if a formal appeal has been filed
- Time period to request a Peer-to-Peer: 3 business days
Reconsideration by the Utilization Management Department
- May be requested if new clinical information is available that was not previously submitted at the time of the initial denial determination
- May be requested if no clinical was submitted and the denial was based on lack of information
- May be requested following discharge from an inpatient level of care
- May be requested if unable to request a Peer-to-Peer within 3 business days after the adverse benefit determination (denial) notification
- Reconsideration cannot be requested after a Peer-to-Peer discussion. Please follow appeal pathway for further dispute rights
- Time periods to request a reconsideration: 14 calendar days
Scheduling a Peer-to-Peer
Please call (425) 398-2603 to request and schedule a Peer-to-Peer discussion or if you have questions regarding the Peer-to-Peer or Reconsideration process.
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:
NOTE: Peer-to-Peer discussions will not be scheduled if a formal member appeal has already been filed. Peer-to-Peer discussions are for medical necessity denials, not administrative denials.
- Member name, date of birth, and Molina ID number, if available
- The authorization request the provider would like to discuss
- New clinical information to be faxed for review prior to the Peer-to-Peer
- Direct contact number for the provider (not a pager)