Utilization Management

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Passport Health Plan by Molina Healthcare's UM Department is designed to provide comprehensive health care management by managing utilization services and benefits effectively and efficiently.

UM Decision Making

Passport Health 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 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. Passport Health Plan Clinical Policy - Corporate guidance documents addressing new or existing technology
  6. InterQual® Criteria (secure provider portal)

Providers can contact Passport Health Plan at (855) 322-4082 to obtain criteria used to make a final determination.

Helpful Web Addresses

  • Prior Authorization forms are available at Frequently Used Forms
  • Log in to Passport Health Provider Portal here
  • Providers may also access the Molina Provider Portal for additional clinical criteria (e.g., InterQual®) 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 Medicaid or Marketplace members:

In order to avoid the appeal process, providers can request a Peer-to-Peer discussion with a Passport Health Plan 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):
  • Passport Health 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 Passport Health Medical Director requests additional information during a Peer-to-Peer, the additional information must be submitted to Passport Health 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. Passport Health 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 Passport Health 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 Passport Health Plan 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.

Forms & Documents

Visit Forms & Documents, download what you need when you need it.