Molina Policies

For Molina Policies, visit www.MolinaClinicalPolicy.com


Passport Policies


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Clinical Policies

Passport by Molina Healthcare (Passport) follows the most current edition of MCG, a nationally recognized set of guidelines.  Passport may employ the Molina Clinical Policies if the MCG guidelines are insufficient. Molina clinical policies are located at www.MolinaClinicalPolicy.com.  Please note, these policies do not constitute plan authorization, an explanation of benefits, or a guarantee of payment.

 

Passport Clinical Policy Links
 

Oncology & Radiology

Passport partners with New Century Health to administer cardiology and oncology services for members age 18+. For clinical policies related to cardiology and oncology, please visit New Century’s website www.NewCenturyHealth.com or click the following link: Compliance and Regulatory Information - New Century Health. Clinical policies are also housed within the provider portal at my.newcenturyhealth.com.

Pharmacy

MedImpact administers pharmacy benefits for Kentucky Medicaid Members. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click here.

 

 
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Payment Policies

Please note that the effective date of any payment policy, and any subsequent revision to a payment policy, shall not be less than 30 days following the date of publication of that revision, pursuant to Section 27.12 of the Kentucky Managed Care Contract.

icon PDF  Assistant at Surgery Effective Date June 17, 2024 

icon PDF  Breast Cancer Genetic Testing Tier 1 vs Tier 2 Effective Date November 5, 2023 

icon PDF  Corrected Claims Effective Date July 18, 2025 

icon PDF  Critical Care Codes when Discharged to Home Effective Date November 5, 2023

icon PDF  DRG Clinical Validation Effective Date August 25, 2023

icon PDF Duplicate Claim Reimbursement Policy Effective Date July 18, 2025 

icon PDF  Early Elective Delivery Payment Policy Effective Date June 20, 2024

icon PDF  Facility Emergency Department Evaluation and Management Leveling Effective Date January 5, 2025

icon PDF  High Level E/M with Preventive Medicine Policy Effective Date November 5, 2023

icon PDF  Hospital Routine Supplies Services Reimbursement Effective Date December 13, 2023

icon PDF  Hydrolyzed Enteral Formula Diagnosis Effective Date November 20, 2023

icon PDF  In-Office Lab Policy Effective Date June 1, 2024

icon PDF  Inpatient Only Procedure Codes Effective Date April 1, 2024

icon PDF  Newborn and NICU Effective Date August 25, 2023

icon PDF  Observation Reimbursement Policy Effective Date June 17, 2024

icon PDF  Optum Pause and Pay Effective Date February 22, 2024

icon PDF  Outpatient Definitive Presumptive Drug Testing Medicaid Medicare Effective Date August 12, 2023

icon PDF  Split Night Sleep Study Effective Date November 5, 2023

icon PDF  Sterilization Effective Date July 18,2025

icon PDF  Therapeutic Behavioral Health Services H2019_H2020 Effective Date September 10, 2023

icon PDF  Timely Filing Reimbursement Policy Effective Date December 26, 2024

icon PDF Vitamin D Assay Testing Effective Date July 18,2025