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:

  1. Applicable federal or state mandates and guidelines as required
  2. American Society of Addiction Medicine (ASAM)
  3. Molina WA Merge Criteria - Molina Apple Health (Medicaid) prior authorization (PA) criteria which includes Health Care Authority (HCA) guidance on certain procedures
  4. Molina WA Pharmacy Criteria - Policies and guidelines intended to be a resource for relevant information about drugs, treatment and coverage
  5. Molina Clinical Policy - Corporate guidance documents addressing new or existing technology
  6. 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 can be found here
  • Molina Clinical Review (MCR) can be found here
  • Prior Authorization forms are available at Frequently Used Forms
  • Log in to Molina’s Provider Portal via here or here
  • Providers may also access the Molina Provider Portal for additional clinical criteria (e.g., MCG care guidelines) and PA information

Contact Utilization 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)

NOTE: Peer-to-Peer discussions will not be scheduled if a formal member appeal has already been filed. Peer-to-Peer discussions are for medical necessity denials, not administrative denials.