One of the goals of 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:
- To determine if prior authorization is required for a service, please see the Prior Authorization page for specific codes requiring authorization.
- Medicaid Behavioral Health and Medical Services Prior Authorization Code Matrix
- Medicaid Prior Authorization Code Matrix for Outpatient Drug Services
- Medicaid Prior Authorization Guide
- Texas Standardized Prior Authorization Request Form for Healthcare Services
- Medicaid Required Essential Information
Please see the Molina Clinical Policy page for specific Molina Clinical policies outlined in the Prior Authorization Code Matrices and/or Adverse Benefit Determination language.
Molina administers Medicaid and CHIP benefits according to the Texas Uniform Managed Care Contract and Texas Department of Insurance guidelines. Providers may locate benefits in the Texas Medicaid Provider Procedures Manual or the Texas Medicaid Fee Schedule or by calling Molina at 855-322-4080.
- Additional coverage for services may be considered on a case-by-case basis based on member's unique needs and medical necessity.
- The DME Exceptional Circumstance provision provides additional coverage for medical supplies and equipment not specifically identified as a covered service. Please see the TMPPM for more information on this rule.
- Members with STAR PLUS benefits may be able to obtain additional services. See the STAR PLUS handbook for additional information or call the Molina Service Coordination team at 1-866-409-0039.
- Molina’s clinical criteria includes Texas Medicaid Provider Procedure Manual, Uniform Managed Care Contract, Uniform Managed Care Manual, Texas Resilience and Recovery Utilization Management Guidelines, MCG® criteria, Molina Clinical Policy (policies developed by designated Corporate Medical Affairs staff in conjunction with Molina physicians serving on the Medical Clinical Policy Committee), Hayes Directory and when appropriate, third party (outside) board-certified physician reviewers.
- Molina ensures that all criteria used for UM decision-making are available to providers and members upon request. To obtain a copy of the UM criteria used in the decision-making process, call our UM department at 1-855-322-4080.
- 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 Benefit Determinations of requested services are rendered by a medical reviewer who is a Texas licensed physician.
How to Contact UM Staff and Medical Reviewer
- Molina UM staff is always available to receive your calls and provide outbound communication regarding UM issues. You may call 1-855-322-4080 during normal business hours Monday through Friday 8:00 AM to 5:00 PM local time. After our normal business hours, you may contact our Nurse Advice Line 1-888-275-8750 for assistance. Members who do not speak English can press 1 at the prompt; the nurse will arrange for an interpreter.
Members and the requesting provider will receive written notification of all UM decisions. For Adverse Benefit Determinations the provider may reach out to discuss the determination with the Molina physician at 1-855-322-4080. If you need any additional assistance, please call the UM Department at 1-855-322-4080.
- 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 does not 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.
* Printed copies of information posted on our website are available upon request.