Molinalogo

Molina works with a large number of doctors and providers in central Arizona. If they are in our Molina provider network, we can help you set up an appointment with them.

If your doctor or provider isn’t in our network, we can reach out to them to see if they would like to join.

Finding a doctor provider is easy with Molina. You can use our Provider Online Directory to look for a provider near you. You can also call Member Services and our team will be happy to help you find the right provider for you.

Yes. You can use our Provider Online Directory to search for a different doctor/provider near you. Once you’ve found a doctor/provider, you can call our Member Services team and let us know the name of the doctor/provider you would like us to assign to you.

You can learn how to get your medicine(s) and more on our benefits and services page.

Yes, as an Molina member, you can get a ride at no cost to any covered service. To schedule a ride, please call our Member Services team. You will be asked to choose your preferred language to start. Once you do, you will press “4” for member, followed by “1” to schedule a ride. Please call at least 72 hours before your visit.

There are some treatments, services and drugs that you need to get approval for before you get them or continue receiving them. This is called a prior authorization. You, your doctor, or someone you trust can ask for a prior authorization. An approval helps let us know if certain services or procedures are medically needed.

Molina discusses some services with your providers before you get them to make sure they are appropriate and needed. Your provider will help you in getting a service authorized from Molina when services need to have an authorization in place.

Some examples of services that need prior authorization are outpatient surgeries, medical supplies (i.e. wheelchairs), a stay in the hospital, pain management, transplants, orthotics and prosthetics. If you have any questions about what needs a prior authorization, call Member Services at (800) 424-5891 (TTY/TDD: 711).

Many services don’t need an authorization. Molina does not reward providers or our own staff for denying coverage or services.

Decisions are based on what is right for each member and on the type of care and services that are needed.

We look at standards of care based on:

• Medical policies
• National clinical guidelines
• Medicaid guidelines
• Your health benefits

Molina does not reward employees, consultants, or other providers to:

• Deny care or services that you need
• Support decisions that approve less than what you need
• Say you don’t have coverage

An authorization is not a guarantee of payment. Members must be eligible at the time services are rendered. Services must be a covered health plan benefit and medically necessary with a prior authorization as per plan policy and procedures. It is the responsibility of the member/provider to check for changes in the prior authorization requirements.

Medical necessity criteria

Molina has a review team to be sure you receive medically necessary services. Doctors and nurses are on this team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards.

The standards we use to determine what is medically necessary are not allowed to be more limiting than those that are used by AHCCCS. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination (decision). These decisions will be made by a qualified health care professional.

If we decide that the requested service is not medically necessary, the decision will be made by a medical or behavioral health professional who may be a doctor or other health care professional that typically provides the care you requested.

You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity.

After we get your request, we will review it under a standard or expedited (fast) review process. You or your doctor can ask for an expedited review if you think that a delay will cause serious harm to your health.

If your request for an expedited review is denied, we will tell you and your case will be reviewed under the standard review process.

Time frames for service authorization decisions

Time frames for standard requests

Molina issues service authorizations for medicines no later than 24 hours from the time we get the request, even if the due date falls on a weekend or a holiday. If we need more information, we will ask for the additional information from the prescriber within 24 hours. The final decision will be sent no later than seven business days from the date of the request.

Molina issues service authorization decisions on requests that are not related to prescriptions as quickly as the member’s condition requires, but no later than 14 calendar days from the initial request. If we need more information to make a decision, we may issue a notice of extension for an additional 14 calendar days.

Time frames for expedited requests

Molina issues expedited service authorizations as quickly as the member’s health condition requires, but no later than 72 hours from the date of receipt, even if the date falls on a weekend or holiday. We may issue a notice of extension for an additional 14 calendar days if Molina needs more time to review your request. For information on the criteria we use to make this decision, please call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am to 6 pm local time/MST.

If the expedited request doesn’t meet the requirements for an expedited review, we may treat your request as a standard request. If you disagree with this decision, you may file a grievance either by calling Member Services or mailing your grievance to:

Molina Healthcare
Attn: Appeals and Grievances Department
5055 E Washington St, Suite 210
Phoenix, AZ 85034

If we do not meet the time frames for making a decision, your request for an expedited decision is denied, or you will get a Notice of Adverse Benefit Determination (NOA). This letter will explain your rights to file an appeal.

For information about the prior authorization process, time frames for making a decision and your rights, please call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am-6 pm local time/MST.

Molina uses nationally accepted, evidence-based criteria, developed by specialty organizations, national policy committees (clinical practice guidelines) and/or industry recognized review organizations in addition to State or Federal criteria or regulations (as appropriate), medical policy or internally developed criteria, physician and clinical judgement to evaluate the necessity of medical and behavioral health services. Molina has adopted evidence-based clinical practice guidelines or protocols for a wide variety of medical conditions and services delivered in different medical and/or behavioral health settings. Molina has adopted MCG evidence-based clinical practice guidelines for management of medical, behavioral, home health, and nursing facility services.

Medical criteria is approved and reviewed annually by the Molina Medical Management Committee and National Policy Committee. In accordance with 42 CFR §438.236 Molina utilizes ASAM criteria for medical necessity determinations for Addiction and Recovery Services. Molina utilizes proprietary diagnostic services criteria for imaging, sleep studies, and certain pain management procedures. These criteria sets are based on sound scientific evidence for recognized settings of care and used to decide the medical necessity and clinical appropriateness of services. If state law requires additional criteria, it is adopted into policy and used.

Molina adopts practice guidelines that meet the following requirements:

• Are based on valid and reliable clinical evidence or a consensus of health care professionals and service providers in a particular field;
• Consider the needs and preference of the members;
• Are adopted in consultation with providers; and
• Are reviewed and updated periodically, as appropriate.

Molina disseminates any revised practice guidelines to all affected providers and, upon request, to members and potential members. The practice guidelines provide a basis for consistent decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply.

Molina takes every allegation of health care fraud, waste and abuse seriously. If you think a provider or someone else is committing fraud, waste or abuse, please report it.

What is fraud?

Fraud is intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to him or herself or some other person.

What is waste?

Waste is the overutilization and/or wrong use of services, resources or practices that result in unnecessary costs.

What is abuse?

Abuse is payment for items or services when there is no legal right to that payment whether or not it was obtained by someone knowingly or purposely misrepresenting facts.

What is the difference between health care fraud and health care waste or abuse?

The difference between fraud and waste or abuse is whether or not someone did it on purpose. Fraud is intentionally lying. The person knows that the information is false. Waste and abuse involve certain actions that don’t make sense. Waste and abuse cause payment for services that are not covered by the plan.

Examples of fraud, waste and abuse:

Providers:

• Providing medical services that are not needed
• “Up-coding” – charging for a more complex or expensive service than was given
• Billing for services that were not provided
• Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
• Billing for rented medical equipment after it has been returned
• Billing twice for the same service
• Billing for more services than can be performed in one day
• Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)

Members:

• Using another person’s name to get Medicaid services
• Sharing a member ID card or using another person’s member ID card
• Visiting several doctors to get multiple prescriptions
• Lying to a care coordinator or someone else to try and get a service you don’t need
• Paying a doctor cash for a prescription that is not needed
• Making false documents by changing:
  • The date of service
  • Prescriptions
  • Medical records
  • Referral forms

How can I report fraud, waste or abuse?

You can call the Molina AlertLine to report fraud, waste and/or abuse.

You can also report fraud by filling out the fraud, waste and abuse form online. Please give as much information as possible. You do not have to give your name. AHCCCS will not share your information with the provider.

Confidential hotline numbers (available 24 hours a day, 7 days a week):

AlertLine: (866) 606-3889
Online:
Magellan Complete Care Special Investigation Unit: (877) 269-7624

You can also report fraud, waste or abuse concerns directly to the AHCCCS/Office of Inspector General (OIG) at:
Office of the Inspector General
701 E Jefferson St, MD 4500
Phoenix, AZ 85034
Phone: (602) 417-4193 (within Maricopa County)
(888) ITS-NOT-OK (487-6686) (outside Maricopa County)
Email: AHCCCSFraud@azahcccs.gov
Website: www.azahcccs.gov/fraud/reportfraud/

Molina is committed to doing business honestly, ethically and following all applicable laws and regulations. Molina’s Corporate Compliance department provides guidance on code of conduct issues, corporate policy and/or laws and regulations.

Health care fraud, waste and abuse prevention tips

You can help Molina stop fraud, waste or abuse by doing these things:

• Review your paperwork from your plan, such as your Explanation of Benefits or Service Verification surveys (if received). Make sure the following information is correct:
  • Date of service
  • Type(s) of service(s) reported
  • Name of the provider billing for those services
• Protect your insurance card and personal information at all times. Do not share it with others.
• Count your pills when picking up a prescription.
• Report anything that seems wrong to Molina as soon as possible.