Authorizations
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Prior Authorization
Prior authorization is required for some services through Molina's Utilization Management department, which is available 24 hours a day, 7 days a week. Providers are expected to submit a pre-service authorization request prior to providing the service or care. Payment will be denied for any services that require an authorization but were not prior authorized.
Molina Healthcare of Virginia and Availity are proud partners in bringing you a better way to submit service authorization requests. We are requesting all inpatient authorization requests now be submitted through our new Availity portal.
If you need training, please visit our Provider Materials page to view our recorded training about the Availity provider authorization portal.
Sign up for the Availity provider portal if you are not yet registered:
1. Go to www.Availity.com
2. Click “Register” in the upper right-hand corner
3. Follow the prompts to register your account
Call Availity at (800) 828-4548 if you have any issues registering.
If you are already submitting requests via the portal please complete the following steps to submit for a concurrent review:
1. Go to “Auth Inquiry” OR “Clinical Update.”
2. Enter in the previous authorization number.
3. Attach continued stay clinical documentation. Your pending request for concurrent review will then be routed to the Utilization Management (UM) team.Prior Authorization Request Forms
- Prior Authorization Request Form
- Prior Authorization/Pre-Service Review Guide
- Virginia Medicaid Prior Authorization Code Matrix
Contact Customer Care with questions.
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518
Fax prior authorization forms to:
- Inpatient Physical Health: (866) 210-1523
- Outpatient Physical Health: (855) 769-2116
- LTSS: (800) 614-8207
- Behavioral Health: (855) 339-8179
- Pharmacy: (844) 278-5731
- Radiology: (877) 731-7218
- Transplant: (877) 813-1206
Please be sure to include all required supporting documentation.
Our Care Managers and health guides work collaboratively in coordinating care with members and their PCP to ensure that all care and services are integrated into the member’s comprehensive treatment plan. We may allow a standing authorization to be approved for members with chronic or disabling conditions. Providers should specifically request these authorizations when working with Molina case and disease managers on care plans for their patients.
Decisions on routine prior authorizations will be rendered within fourteen calendar days from the date of receipt of the request. Decisions on expedited prior authorization requests will be rendered within 72 hours from the date we receive the request if we determine that the request qualifies for expedited consideration. We will notify you if the request will not be considered as an expedited request. We base our decisions for approved services on appropriateness of care and service and existence of coverage.
- Utilization Management
Molina's Utilization Management department performs many functions including but not limited to concurrent review, prior authorization, discharge planning assistance and retrospective review. Our Utilization Management program’s goal is to optimize the use of healthcare resources for our members. Services provided are not less than the amount, duration, and scope for the same services delivered to fee-for-service Medicaid members. Medically necessary services are no more restrictive than used in the DMAS defined program. Molina supports continuity and coordination of care for physical, dental, and behavioral health providers. Our members’ health is always our number one concern.
Molina makes the utilization management criteria available in writing, by mail or fax:
Mail:
Molina Healthcare
Attn: Utilization Management Department
3829 Gaskins Road
Glen Allen, VA 23233Fax:
Inpatient Physical Health: (866) 210-1523
Outpatient Physical Health: (855) 769-2116
LTSS: (800) 614-8207
Behavioral Health: (855) 339-8179
Pharmacy: (844) 278-5731
Radiology: (877) 731-7218
Transplant: (877) 813-1206Molina providers should call our toll-free number with any utilization management questions. We’re available Monday through Friday from 8 a.m. to 6 p.m. local time. Providers can leave voice mail messages after business hours. An on-call nurse is available after hours for urgent concerns.
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518
Molina Healthcare of Virginia and Availity are proud partners in bringing you a better way to submit service authorization requests. We are requesting all inpatient authorization requests now be submitted through our new Availity portal.If you need training, please visit our Provider Materials page to view our recorded training about the Availity provider authorization portal.
Sign up for the Availity provider portal if you are not yet registered:
1. Go to www.Availity.com
2. Click “Register” in the upper right-hand corner
3. Follow the prompts to register your account
Call Availity at (800) 828-4548 if you have any issues registering.
If you are already submitting requests via the portal please complete the following steps to submit for a concurrent review:
1. Go to “Auth Inquiry” OR “Clinical Update.”
2. Enter in the previous authorization number.
3. Attach continued stay clinical documentation. Your pending request for concurrent review will then be routed to the Utilization Management (UM) team. - Member Support Services
Molina Member Services is available to help our members if they have any questions about their benefits and services.
- Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
- Molina offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are Molina members and offer them appropriate assistance.
If members receive care from out-of-network providers without prior authorization, Molina will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives an Molina member emergency care, the service will be paid.
Visit our Forms page for the most up-to-date list of services requiring prior authorization. Refer to the Molina provider manual for more information about prior authorization.
- Medical Necessity Criteria
Molina utilizes nationally recognized criteria, MCG Guidelines, to determine medical necessity and appropriateness of care. The criteria used are designed to assist clinicians and providers in recognizing the most effective healthcare practices used today which ensure quality of care to our members. These criteria are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about their patient’s healthcare needs. Molina defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services. Molina also has polices developed to complement nationally recognized criteria. If a member’s clinical documentation does not meet the criteria, the case is forwarded to Molina's Medical Director for further review and determination. Molina's Medical Director is available to discuss individual cases with attending physicians upon request.
Utilization review determinations are based only on appropriateness of care, service and benefit coverage. Molina does not reward providers or any staff members for adverse decisions for coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.
Upon request, Molina will provide the clinical rationale or criteria used in making medical necessity determinations. You may request the information by calling
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518
or faxing the Utilization Management Department at
- Inpatient Physical Health: (866) 210-1523
- Outpatient Physical Health: (855) 769-2116
- LTSS: (800) 614-8207
- Behavioral Health: (855) 339-8179
- Pharmacy: (844) 278-5731
- Radiology: (877) 731-7218
- Transplant: (877) 813-1206
If you would like to discuss an adverse decision with Molina's Medical Director, please call the Utilization Management department within five business days of the determination.
If the member’s ordering physician would like to discuss an adverse decision with Molina's Medical Director, they may call the Utilization Management department within five business days of the determination.
As LTSS services are not physician driven, these requests are out-of-scope for Peer-to-Peer discussions.Post-stabilization services
Prior authorization is not required for coverage of post-stabilization services when these services are provided in any emergency department or for services in an observation setting. To request authorization for an inpatient admission or if you have any questions related to post-stabilization services, please contact the Utilization Management department.
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518
- Care Management
Molina provides a comprehensive Case Management (CM) program to all members who meet the criteria for services. The CM program focuses on procuring and coordinating the care, services, and resources needed by members with complex issues through a continuum of care. Molina adheres to Case Management Society of America Standards of Practice Guidelines in its execution of the program.
Molina case managers are licensed professionals and are educated, trained and experienced in the Case Management process. The CM program is based on a member advocacy philosophy, designed and administered to assure the member value-added coordination of health care and services, to increase continuity and efficiency, and to produce optimal outcomes. The CM program is individualized to accommodate a member’s needs with collaboration and approval from the member’s PCP. The Molina case manager will arrange individual services for members whose needs include ongoing medical care, home health care, rehabilitation services, and preventive services. The Molina case manager is responsible for assessing the member’s appropriateness for the CM program and for notifying the PCP of the evaluation results, as well as making a recommendation for a treatment plan.
Members with the following conditions may qualify and should be referred to our Case Management Department:
- Hospitalizations (Primary Diagnoses): Psychiatric, substance abuse, admissions for controllable diseases
- Social issues: Medical child neglect
- Life Threatening Chronic Diseases: HIV/AIDS, Cancer, Tuberculosis
- Members with three or more consecutive missed appointments
- Significant impairments: hearing, vision, mobility, cognitive/mental impairments
- Pregnant Patients
- Members that failed to meet health prevention guidelines
- Newly diagnosed patients: asthma, diabetes, HIV/AID, mental illness, substance abuse, failure to thrive, low birth weight, critically ill newborn, newborns with NICU stay greater than 24 hours
- High risk populations that would benefit from Case Management Services
- Cases identified by PCP, Quality Improvement Department, Complaint or Grievance, Molina Medical Director, Member, Hospital Discharge Planner, Quarterly Administrative Claims Review, Virginia State Department of Health
High risk populations will be discussed quarterly at the QM Committee meetings. Categories for review may be modified depending on the needs of the membership.
Referrals to the CM program may be made by contacting Molina at:
- CCC Plus: (800) 424-4524
- Medallion 4.0: (800) 424-4518