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Molina Healthcare's Utilization Management

One of the goals of the Molina Healthcare Utilization Management (UM) department is to render appropriate UM decisions that are consistent with objective clinical evidence. To achieve that goal, Molina Healthcare maintains the following guidelines:

Appropriate Professionals

  • Medical information received by our providers is evaluated by our highly trained UM staff against nationally recognized objective and evidence-based criteria. We also take individual circumstances and the local delivery system into account when determining the medical appropriateness of requested health care services. All adverse determinations regarding medical necessity of requested services are rendered by a medical reviewer who is either a physician or a dentist. 

Criteria

  • Molina Healthcare's clinical criteria includes federal and state mandates and guidelines, McKesson InterQual® criteria, Hayes Directory, Agency for Healthcare Research and Quality guidelines, Up to Date, Apollo's Managed Care Guidelines, Official Disability Guidelines (ODG), CareCore Direct DNA Criteria, Texas Medicaid Provider Procedures Manual, Medicare Manual of Criteria, Texas Resiliency and Recovery Utilization Management Guidelines Medicare National and Local Coverage Determinations, applicable Medicaid Guidelines, Molina Healthcare Medical Coverage Guidance Documents (developed by designated Corporate Medical Affairs staff in conjunction with Molina Healthcare physicians serving on the Medical Coverage Guidance Committee) and when appropriate, third party (outside) board-certified physician reviewers.
  • Molina Healthcare ensures that all criteria used for UM decision-making are available to providers upon request. To obtain a copy of the UM criteria used in the decision-making process, call our UM department.

How to Contact UM Staff and Medical Reviewer

  • Molina Healthcare UM staff is available to receive your calls and provide outbound communication regarding UM issues during normal business hours. After normal business hours, you may contact our Nurse Advice Line (888) 275-8750 or (866) 648-3537 (Spanish) for assistance.
  • As the requesting provider, you will receive written notification of all UM denial decisions. The notification will include the name and telephone number of the Molina Healthcare physician that made the decision. Please feel free to call him or her to discuss the case. If you need assistance contacting a medical reviewer about a case please call the UM Department.

Affirmative Statement

  • It is important to remember that:
    1. UM decision making is based only on appropriateness of care and service and existence of coverage.
    2. Molina Healthcare does not specifically reward providers or other individuals for issuing denials of coverage or care.
    3. UM decision makers do not receive incentives to encourage decisions that result in underutilization.

To determine if prior authorization or pre-service review is required for a service, please see the Prior Authorization Guide and Prior Authorization Form (Coming Soon) for more information.

Contact Us

Utilization Management (UM) staff is available 8 a.m. to 5 p.m. Monday to Friday at (855) 322-4080.

For assistance with UM questions after normal business hours, call our Nurse Advice Line (888) 275-8750 (English) or (866) 648-3537 (Spanish).

Prior Authorization Fax Number: (866) 420-3639

Behavioral Health Authorization Fax Number: (866) 617-4967; For Behavioral Health Services in the Dallas Service Area, please fax NorthSTAR (972) 906-2789 or after hours (877) 299-1179.

Radiology, OB, NICU and Transplant Authorizations Fax Number: (877) 731-7218


New Technology

Molina Healthcare evaluates the appropriate use of new developments in technology and the application of existing technologies relating to medical and behavioral procedures, equipment, devices and pharmaceuticals for inclusion into Molina Healthcare benefit plan decision making processes. This process allows Molina Healthcare to:

  • Keep abreast of ongoing changes in technology
  • Provide access to obtain safe and effective care
  • Review information from appropriate governmental regulatory bodies and from published scientific evidence
  • Obtain input from specialists and professionals with unique knowledge about the specific technology reviewed
  • Outline the variables used in making determinations including, but not limited to, experimental and investigational procedures
  • Review the criteria and procedures for applying them annually and update the criteria when appropriate

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