- 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 under utilization by providing financial incentives to deny coverage.
- Member support services
Molina Member Services is available to help our members if they have any questions about their benefits and services.
- Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
- Molina offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are Molina members and offer them appropriate assistance.
If members receive care from out-of-network providers without prior authorization, Molina will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives an Molina member emergency care, the service will be paid.