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Utilization Management

The Healthcare Services (formerly Utilization Management) Department conducts inpatient review on inpatient cases and processes Prior Authorizations/Service Requests. The Healthcare Services (HCS) Department also performs Care Management for Members who will benefit from Care Management services. Participating Providers are required to interact with Molina’s HCS department electronically whenever possible. Prior Authorizations/Service Requests and status checks can be easily managed electronically using Molina’s Provider Web Portal.

Managing Prior Authorizations/Service Requests electronically provides many benefits to Providers, such as:

  • Easy to access 24/7 online submission and status checks
  • Ensures HIPAA compliance
  • Ability to receive real-time authorization status
  • Ability to upload medical records
  • Increased efficiencies through reduced telephonic interactions
  • Reduces cost associated with fax and telephonic interactions

 

Molina offers the following electronic Prior Authorizations/Service Requests submission options:

  • Submit requests directly to Molina Healthcare of New York via the Provider Portal. See our Provider Web Portal Quick Reference Guide or contact your Provider Services Representative for registration and submission guidance.
  • Submit requests via 278 transactions. See the EDI transaction section of our website for guidance.

 

Molina requires prior authorization for specified services as long as the requirement complies with Federal or State regulations and the Molina Hospital or Provider Services Agreement. The list of services that require prior authorization is available in narrative form, along with a more detailed list by CPT and HCPCS codes. Molina prior authorization documents are updated annually, or more frequently as appropriate. To ensure the most current information is being utilized, Providers are encouraged to access the guide posted on the Molina website at www.molinahealthcare.com.

Requests for prior authorizations to the UM Department may be sent by telephone, fax, mail based on the urgency of the requested service, or via the Provider Web Portal. Contact telephone numbers, fax numbers and addresses are noted in the introduction of this section. If using a different form, the prior authorization request must include the following information:

  • Member demographic information (name, date of birth, Molina ID number, etc.)
  • Clinical information sufficient to document the Medical Necessity of the requested service
  • Provider demographic information (referring Provider and referred to Provider/facility)
  • Requested service/procedure, including all appropriate CPT, HCPCS, and ICD-10 codes
  • Location where service will be performed
  • Member diagnosis (CMS-approved diagnostic and procedure code and descriptions)
  • Pertinent medical history (include treatment, diagnostic tests, examination data)
  • Requested Length of stay (for inpatient requests)
  • Indicate if request is for expedited or standard processing

 

Prior Authorization Pre-Service Review Guide

Prior Authorization Request Form

Codification Matrix

For more information, please view the Provider Manual

 

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