Authorizations

  • 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