Authorizations

Utilization Management (UM)

We use evidence-based clinical practice guidelines when making decision about members’ care.

Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.

When determining the medical appropriateness of a service, we apply these criteria while taking into account individual circumstances and the local delivery system.

Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage underutilization by providing financial incentives to deny coverage.

View our Clinical Practice Guidelines
Requesting Prior Authorization
Notwithstanding any provision in the Provider Agreement that requires Provider to obtain a prior authorization directly from Molina, Molina may choose to contract with external vendors to help manage prior authorization requests.

For additional information regarding the prior authorization of specialized clinical services, please refer to the prior authorization tools:
- Prior Authorization Code Look-up Tool
- Prior Authorization Code Matrix
- Prior Authorization Guide
- Prior Authorization Code Changes

Availity Essentials portal: Participating Providers are encouraged to use the Availity Essentials portal for prior authorization submissions whenever possible. Instructions for how to submit a prior authorization request are available on the Availity Essentials portal. The benefits of submitting your prior authorization request through the Availity Essentials portal are:

Create and submit Prior Authorization Requests.
Check status of Authorization Requests.
Receive notification of change in status of Authorization Requests.
Attach medical documentation required for timely medical review and decision making.

Fax: The Prior Authorization Request Form can be faxed to Molina at: (833) 832-1015.

Phone: Prior authorizations can be initiated by contacting Molina’s Healthcare Services department at (844) 782-2678. It may be necessary to submit additional documentation before the authorization can be processed.

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