Bariatric Surgery Program
For Molina Healthcare adult members of Apple Health (Medicaid). The Bariatric Surgery Program is available to Washington State residents only.
Program Eligibility Criteria
Program eligibility is based on Washington Administrative Code (WAC) 182-531-1600 (apps.leg.wa.gov) and Health Technology Clinical Committee (HTCC) Guideline 20150515B (hca.wa.gov).
Read Molina's Bariatric Surgery Program Overview Flyer for full program eligibility criteria and program requirements.
To receive prior authorization from Molina to begin Stage II, providers must complete the Molina Medicaid Bariatric Surgery Criteria Pre-Surgical Assessment Form and fax it to Molina Utilization Management (UM) at (800) 767-7188 along with all required documentation.
If a member is unable to meet the 5% weight loss goal, complete appointments, etc. or needs to revise their initial weight then providers may complete the relevant form and fax it to Molina UM at (800) 767-7188. All requests must include supportive documentation and exception or extension requests must also include a summary detailing medical issues or barriers.
- Bariatric Surgery Program Exception Request for Stage II
- Bariatric Surgery Program Extension Request for Stage II
- Bariatric Surgery Program Request for Weight Revision