Provider care management resources
Learn how Molina’s Case Management program supports members with complex needs through coordinated care, provider collaboration and access to care standards.
Molina offers a comprehensive Case Management (CM) program to support members with complex medical, behavioral, and social needs. The program brings care, services, and resources together across the full continuum of care. This approach helps improve health outcomes, strengthens care continuity, and supports appropriate use of health care services.
Molina’s CM program follows the Case Management Society of America Standards of Practice Guidelines. The program reflects a strong focus on member advocacy, close collaboration with providers, and care plans tailored to each member’s needs.
Molina case management approach
Molina case managers are licensed health care professionals with experience in care coordination, complex case management, and population health. They work closely with members to understand needs and support care across settings.
Case Management services follow a member-centered approach. Services align to each member’s needs, goals, and personal circumstances to support coordinated, meaningful care.
Key elements of Molina’s Case Management approach include:
• Individualized assessment and care planning
• Collaboration with the member and the Primary Care Provider (PCP)
• Coordination of medical, behavioral health, and community-based services
• Ongoing monitoring and reassessment to support strong outcomes
Case Managers partner with providers to support treatment plans, reduce barriers to care, and connect members to appropriate services across care settings.
Role of the Provider in Case Management
Providers play an important role in the success of Case Management services. Molina Case Managers work with Primary Care Providers and Specialists to align care plans with clinical goals and member preferences.
With provider input and member consent, Case Managers assist with:
• Coordination of ongoing medical care
• Home health and rehabilitation services
• Preventive and wellness services
• Transitions of care after hospital stays or other care events
The Case Manager shares assessment findings and care recommendations with the Primary Care Providers and supports care plan execution when appropriate.
Members who may benefit from case management
Providers are encouraged to refer members who might benefit from Case Management services. Members with the following needs or circumstances often qualify for review:
• Recent or frequent hospital stays, including behavioral health or substance-use treatment
• Life-threatening or complex chronic conditions
• High-risk pregnancies or newborns with intensive care needs
• Functional, cognitive, sensory, or mobility limitations
• Serious mental illness or substance-use disorders
• Gaps in preventive care or challenges following treatment plans
• Missed appointments or difficulty accessing care
• Social or environmental factors affecting health outcomes
• New diagnoses involving chronic or complex conditions
• Identification through provider referral, hospital review, quality teams, or care review activities
Molina reviews high-risk populations and referral categories on a regular basis as part of Quality Management activities to align services with member needs.
Referrals to Case Management
Referrals to Case Management are accepted from:
• PCPs or specialists
• Hospital discharge planners
• Molina clinical or quality teams
• Members or authorized representatives
Providers share relevant clinical, demographic, and social details to support the review process. Molina Case Management teams evaluate referrals to confirm eligibility and next steps. To submit a referral, contact Molina Healthcare Member Services. Visit Contact Us, then select the state and line of business for the member’s plan.
Access to care standards
Molina maintains access to care standards to support timely medical and behavioral health services. These standards apply to contracted PCPs and participating specialists. Molina Quality teams monitor compliance on an ongoing basis.
Providers meet appointment availability expectations, including after-hours coverage and emergency access.
Access care standards may vary by state. Please review your state's standards for compliance.
Appointment access standards
Providers are responsible for offering appointments within established timeframes, including:
Medical services
• Routine care, asymptomatic, within 30 calendar days
• Routine care, symptomatic, within 7 calendar days
• Urgent care, within 24 hours
• After-hours care, available 24 hours a day, 7 days a week
• Specialty care, high volume or high impact, within 45 calendar days
• Urgent specialty care, within 24 hours
• Obstetrical care, based on trimester-specific standards
• Dental care, routine and urgent standards apply
Behavioral health services
• Emergency services, immediately
• Urgent care, within 24 hours
• Routine care, within 14 calendar days
• Follow-up routine care, within 7 calendar days
Appointment access standards vary by state and line of business. Providers should review the provider handbook for details.
Office wait times
For scheduled appointments, in-office wait times should not exceed 45 minutes. Providers are expected to monitor and manage wait times to support a positive member experience.
After-hours access
Providers must ensure access to care outside of regular office hours. This includes maintaining a 24/7 phone system that allows members to reach clinical guidance or be directed appropriately for urgent or emergency care.
After-hours messaging must clearly instruct members experiencing emergencies to call 911 or go to the nearest emergency room.