Utilization Management (UM) Program
Molina’s UM Department is designed to provide comprehensive health care management by managing utilization services and benefits effectively and efficiently.
UM Decision Making
Molina follows a hierarchy of medical necessity decision-making, with federal and state regulations taking precedence. The following medical necessity criteria are used and available to contracted providers:
- Applicable federal or state mandates and guidelines as required
- American Society of Addiction Medicine (ASAM)
- Molina WA Merge Criteria - Molina Apple Health (Medicaid) prior authorization (PA) criteria which includes Health Care Authority (HCA) guidance on certain procedures
- Molina WA Pharmacy Criteria - Policies and guidelines intended to be a resource for relevant information about drugs, treatment and coverage
- Molina Clinical Policy - Corporate guidance documents addressing new or existing technology
- MCG care guidelines (secure provider portal)
Providers can contact Molina at (855) 322-4082 to obtain criteria used to make a final determination.
Helpful Web Addresses
- Molina Clinical Policy (MCP)
- Molina Clinical Review (MCR)
- PA forms are available on the Frequently Used Forms page
- Log in to Molina’s Provider Portal via OneHealthPort or here
- Providers may also access the Molina Provider Portal for additional clinical criteria (e.g., MCG care guidelines) and PA information
- Information regarding Sepsis Guidelines
- Molina uses the revised sepsis guidelines issued by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) for all product lines.
- For additional information, please see: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer, M., Deutschman, C. S., et al. JAMA 2016; 315(8):801-810.
Contact UM Staff
Providers can contact us at our toll-free number (800) 869-7185 between 8 a.m. and 5 p.m. PST, Monday - Friday. We are available to discuss any utilization management requirements, processes or procedures.
Peer-to-Peer Discussion and Reconsideration Process
For Apple Health (Medicaid) or Marketplace members:In order to avoid the appeal process, providers can request a Peer-to-Peer discussion with a Molina Medical Director. The requesting provider has 10 business days for inpatient, or within 5 business days of discharge, and 10 business days of pre-service from receipt of the adverse benefit determination (denial) notification (verbal or fax notification), or any time before a decision is made, to schedule a Peer-to-Peer.
If the Peer-to-Peer request is made more than 10 business days after the adverse benefit determination (denial) notification (or the member has discharged more than 5 business days from an inpatient facility):
- Molina will instruct the requesting provider to file an appeal on behalf of the member. You must have written consent from the member to appeal on their behalf.
- Once an appeal is formally requested and filed, any notes from the Peer-to-Peer will be reviewed during the appeal process.
- If a Molina Medical Director requests additional information during a Peer-to-Peer, the additional information must be submitted to Molina within 2 business days of the discussion in order to be considered during the Peer-to-Peer process. If the information is received after this timeframe, the initial decision will be upheld.
Scheduling a Peer-to-Peer
Please call (425) 398-2603 to request and schedule a Peer-to-Peer discussion. Molina Medical Directors will be available to schedule a Peer-to-Peer Monday through Friday from 9 a.m. to 4 p.m. PST, excluding holidays. For Advance Imaging (AI) authorizations, please call (855) 714-2415 (option 1). A Molina Medical Director will call you at your scheduled date and time, at the direct number provided.
When scheduling a Peer-to-Peer, you will be asked to provide:
- Member name, date of birth, and Molina ID number, if available
- The authorization request the provider would like to discuss
- New clinical information to be faxed for review prior to the Peer-to-Peer
- Direct contact number for the provider (not a pager)