Prior Authorizations in Mississippi

When requesting a service PA, providers should use Molina’s PA form online.

Information to support general service authorization decision making includes:

• Completed PA Form
• Current (up to 6 months), adequate member history related to the requested services
• Relevant physical examination that addresses the problem
• Relevant lab or radiology results to support the request (including previous MRI, CT, Lab, or X-ray report/results)
• Relevant specialty consultation notes
• Any other information or data specific to the request

Information generally required to support Home Health authorization decision making includes:

• Completed PA Form
• Signed MD order
• Supporting clinical documentation from the certifying physician, and
• A plan of care

Information generally required to support Durable Medical Equipment (DME) authorization decision making includes:

• Completed PA Form
• Signed MD order
• An itemized quote
• An assessment
• Certification of Medical Necessity (CMN) form

Information generally required to support Physical, Occupational or Speech Therapy Services authorization decision making includes: Completed PA Form

• Signed MD order
• A therapy evaluation
• Concurrent evaluation
• Plan of Care (POC) with certification date span

Information generally required to support Behavioral Health authorization decision making include:

• Completed PA Form
• A recent evaluation
• A treatment plan for the requested services

Information generally required to support Ablation/Ligation/Vein Stripping and Sclerotherapy authorization decision making includes:

• Completed PA Form
• Member evaluation and complaints
• Diagnosis studies (ultrasound or other imagining test) with results:
• Documentation of vein size and reflux (if applicable)
• Documentation of presence or absence of Deep vein thrombosis (DVT), aneurysm, and or tortuosity
• A list of other conservative treatments attempted with duration for each
• Documentation of pulses
• Treatment plan (including which extremity and vein will be treated)

Information generally required to support Bariatric Surgery authorization decision making includes:

• Completed PA Form
• Member evaluation with recent Surgeon’s notes:
• Weight
• Height
• BMI
• Past medical history (comorbidities)
• Failed previous nonsurgical obesity treatments, including structured diet programs.
• Evidence that member is prepared to take part and follow postoperative instructions
• Evidence that member is an appropriate psychological/psychiatric candidate for bariatric surgery (Preoperative Psychological/Psychiatric Evaluation)
• Surgeon qualifications
• Plan of care

Information generally required to support External Defibrillator authorization decision making includes:

• Completed PA Form
• Signed MD order/prescription
• Member’s evaluation and clinical notes include, but not limited to:
• Cardiac history (history of cardiac arrest/ventricular fibrillation or ventricular tachyarrhythmia)
• Familial or inherited conditions
• History of either prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction
• History of a previously implanted defibrillator
• Coronary artery disease with a documented prior myocardial infarction with a measured left ventricular ejection fraction
• Members with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI)
• Members with nonischemic dilated cardiomyopathy
• NYHA Functional Classification
• Evidence that implantation surgery is contraindicated

Information generally required to support Pneumatic Compressor authorization decision making includes:

• Completed PA Form
• Signed MD order/prescription
• Clinical documentation supporting member’s diagnosis (Lymphedema/Chronic Venous Insufficiency)
• Symptoms and objective findings, including measurements that establish severity of condition
• A four-week trial of conservative therapy
• Previous treatments (including dates of trial and response of treatment)
• Plan of care including reason device

Information generally required to support Injections authorization decision making includes:

• Completed PA Form
• Signed MD order/prescription
• Offices notes:
• Member’s history of Lumbar, Cervical, or Thoracic radiculopathy (as applicable).
• Member’s history on physical examination and imaging that supports pain due to one of the following: Disc herniation, post-laminectomy syndrome, or acute herpes zoster.
• Member's pain is sufficiently severe to affect quality of life or functional ability, and provider assessed before initial and subsequent injections as well as at each follow-up visit.
• Member’s pain with a duration of at least four weeks with failure of, or inability to tolerate noninvasive conservative care.
• Member’s response to previous injection, if applicable.
• Physical therapy for a minimum of eight (8) sessions, unless a documented contraindication or intolerance to physical therapy is provided.
• Activity or exercise modification.

Information generally required to support Hospital Bed authorization decision making includes:

• Completed PA Form
• Signed MD orders/prescription
• Offices notes:
• Member’s condition requires body positioning that cannot be accomplished in ordinary bed.
• Member’s condition requires elevation of head of bed due to respiratory issues or risk for aspiration.
• Members require special equipment that necessitates hospital bed use (e.g., traction equipment)
• Member/Member’s caregiver status
• Certification of Medical Necessity (CMN) form

Providers must obtain prior authorization (PA) for services that require it; otherwise, coverage may not apply unless the situation is an emergency. Receiving approval does not guarantee payment; services must also meet eligibility, coding and benefit limits. Non-contracted providers must request PA for elective services. Molina reimburses emergency care delivered by non-contracted providers at standard rates.