Provider prior authorizations
Information for providers on submitting a request for prior authorization, locating forms and contacting us.
Prior authorization and utilization management overview
Molina Healthcare is committed to ensuring that members receive medically necessary, appropriate and timely care. Our utilization management (UM) and prior authorization (PA) processes are designed to support providers by applying evidence-based clinical standards, meeting federal and state regulatory requirements and promoting transparency in medical decision-making.
This page outlines how UM determinations are made, how providers can engage with the Prior Authorization process and the tools available to support efficient and informed submissions.
Utilization management (UM) decisions
An organizational determination is any decision made by Molina, or by a delegated Medical Group, IPA or other delegated entity, regarding:
Molina follows a structured hierarchy for medical necessity decision-making. Federal and state regulations take precedence, and Molina covers all services and items required under applicable regulatory requirements.
All utilization determinations are made in a timely manner to accommodate the clinical urgency of the situation and are consistent with:
Board-certified, licensed reviewers from appropriate specialty areas are utilized as needed. Requests that do not meet medical necessity criteria are reviewed by a Molina Medical Director or a licensed health care professional with appropriate clinical expertise related to the member’s condition or disease.
Where applicable, Molina Clinical Policies are publicly available at molinahealthcare.com/providers/resources/policies/clinical. State-specific criteria are applied before Molina-specific criteria when available.
Medical necessity standards
A service is considered medically necessary when it is directed toward the prevention, diagnosis or treatment of illness, injury, disease or disability, and is required to maintain, improve or protect health.
Medically necessary services must meet all the following criteria:
Generally accepted standards of medical practice are based on credible scientific evidence published in peer‑reviewed medical literature, professional society recommendations and the clinical judgment of practitioners in relevant specialties.
The fact that a provider has prescribed, recommended or approved a service does not, by itself, establish medical necessity or coverage.
Medical necessity review process
Molina reimburses only for services determined to be medically necessary. Medical necessity review may occur:
In determining medical necessity, Molina considers independent professional medical judgment in conjunction with:
All UM requests that may result in an adverse medical necessity determination are reviewed by a Molina Medical Director, Pharmacy Director or appropriately licensed health care professional.
Levels of administrative and clinical review
The UM review process includes:
Administrative review
Clinical review
Clinical determinations are performed only when appropriate and in accordance with regulatory requirements.
Prior authorization lookup tool
Molina requires prior authorization (PA) for specified services. The list of services that require prior authorization is available on the Prior Authorization Lookup tool.
There you will enter the member’s state, health plan benefit they are covered under, their line of business and CPT/HCPCS Code for the service they are seeking to receive.
Once entered, the tool will share the services prior authorization status of Required or Prior Authorization Not Required (Exclusions Apply).
Exclusions indicate occasions when prior authorization is required for a service when one may not otherwise be required. Those exclusions include:
Prior authorization submission
Providers can manage prior authorizations through the Availity provider portal.
Once logged in, you can:
To submit an authorization:
Provider may also submit PAs by using the Molina Prior Authorization forms available on the state specific website.
Services performed without required authorization may not be eligible for payment. Authorization does not guarantee payment, and Molina retains the right to review eligibility, benefit limitations, coding accuracy and site of care appropriateness.
Emergency services, as defined by federal and state law, are excluded from prior authorization requirements.
Clinical information requirements
Molina requires submission of complete clinical documentation to support medical necessity determinations. Required documentation may include, but is not limited to:
Expedited and urgent requests
An expedited or urgent prior authorization request may be submitted when standard timeframes could seriously jeopardize the member’s life, health, safety or ability to regain maximum function.
Supporting clinical documentation is required to justify expedited review.
UM decision timeframes
All prior authorizations are reviewed and decisioned within the applicable regulatory timeframe.*
Molina makes all UM decisions within required timeframes based on the clinical urgency of the situation.
*UM and PA timeframes may vary by state, program and line of business (LOB). Providers should refer to the applicable Molina Provider Manual for state‑specific and product‑specific requirements.
Prior Authorization Lookup tool
Pharmacy prior authorization and drug coverage
Molina maintains a structured pharmacy benefit designed to ensure members have access to safe, effective and clinically appropriate medications.
Click below to access information for the applicable state to support your member.