Providers

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Communications & Important Reminders

As our health care partner, it’s important that you have all the latest information about Molina’s operations. Please click the Provider Communication links below for up-to-the-minute details about Molina’s key plan updates, legislative changes, industry trends and news, upcoming meetings, training opportunities, and emergent issues in the industry.

Provider Newsletter Communications & Important Reminders Covid-19

Announcements and Reminders

Attention Marketplace Providers

J Code prior authorizations can be sent directly to the Pharmacy Department.

Important Reminder

Please notify Molina Healthcare at least 30 days in advance when you have any of the following:

  • Change in office location, office hours, phone, fax, or email
  • Addition or closure of office location
  • Addition or termination of a provider
  • Change in Tax ID and/or NPI
  • Open or close your practice to new patients (PCPs only)

Molina Preauthorization Information - Health Care Services

The following preauthorization information is available to providers and the general public. Please Note: Preauthorization and Prior Authorization are referenced on the same basis.

Health Care Services

There are in excess of 14,800 billable service codes. Molina requires authorization for approximately 20% of these service codes. We recognize the delicate balance between appropriate utilization management and provider administrative burden. We review our preauthorization patterns and our requirements quarterly to assure the best use of preauthorization requirements.

Preauthorization Process Disclosure

At Molina Healthcare, it is not a condition of employment or part of the evaluation process to base performance ratings, allow compensation or financial incentives for:

  • The number of adverse benefit determinations
  • Limitations on length of stay, benefits, service or charges
  • The number or frequency of telephone calls or other contacts with health care providers or patients
  • To encourage decisions that result in under-utilization
  • Preauthorization decision-making is based only on the appropriateness of care, service and existence of coverage.

Preauthorization Information Navigation Guide
Preauthorization Code Matrix
Preauthorization Guide
Preauthorization Statistics Abbreviation Guide
Preauthorization Forms click here

Preauthorization Statistics

Molina believes in transparency and is providing preauthorization statistics for the prior calendar year.

By Provider type and Specialty
By Indication Offered
Approvals and Denials
Summary of Appeals & Independent Review Organization  

Molina Preauthorization Information - Pharmaceutical Services

The following preauthorization information is available to providers and the general public. Please Note: Preauthorization and Prior Authorization are referenced on the same basis.

Preauthorization is an approval by Molina that confirms that a requested prescription service has been determined to be Medically Necessary and is covered under the plan. Preauthorization is not a guarantee of payment for services.

Payment is made based upon the following:

  • Benefit limitations;
  • Exclusions;
  • Member eligibility at the time the services are provided and
  • Other applicable standards during the claim review process.

Molina Healthcare has a list of drugs that we will cover. The list is known as the Drug Formulary. The drugs on the list are chosen by a group of doctors and pharmacists from Molina Healthcare and the medical community. Certain drugs on the Drug Formulary require preauthorization. Molina also has a process to allow you to request and gain access to clinically appropriate drugs that are not covered under the plan. Molina Healthcare may cover specific non-formulary drugs when the prescriber documents in the medical record and certifies that the Drug Formulary alternative has been ineffective in the treatment of the Member’s disease or condition, or the Drug Formulary alternative causes or is reasonably expected by the prescriber to cause a harmful or adverse reaction in the Member. The drug formulary which indicates the drugs requiring preauthorization can be found here.

Preauthorization Statistics

Molina complies with state requirements to provide additional information in relation to the outcome of preauthorization requests. Select the links below to review specified statistics related to the results of Molina’s preauthorization process.
By Provider type and Specialty
By Indication Offered
Approvals and Denials
Summary of Appeals & Independent Review Organization

Molina Telehealth Policy

Primary Care Designation Reminder

As a Primary Care Provider by designation, you can always access the roster of Molina Marketplace members assigned to your practice via your provider portal. However, you do not need to be designated as a member’s PCP to provide services to Molina members. Eligibility and benefit terms apply.

PsychHub

PsychHub is an online plaform for digital mental health education. Molina Providers are able to access PsychHub online learning courses through their Learning Hub for FREE. Contact your local Molina provider services team.

Read More PsychHub

Marketplace Service Areas

View the states, counties, and communities we serve

Benefits of Provider Portal

Take care of business on your schedule. Available 24/7, the Provider Portal gives you an easy way to make short work of a number of tasks, including:

• Check Member Eligibility

• Submit and check the status of your claims

• Submit and check the status of your service or request authorizations

• View your HEDIS scores

• Prior Auth Lookup Tool

Click to Login or Register Benefits of Provider Portal

Stay up to date with our Molina Resources

Health Resources

Quality Improvement | HEDIS | CAHPS | Culturally and Linguistically Appropriate Resources | Clinical Practice Guidelines | Preventive health guidelines | Health management | Integrated case management | Molina’s 24 Hour Nurse Advice line | Opioid Safety Resources | Utilization Management | HEDIS/CAHPS Tip sheets | Provider Education Series

EDI ERA/EFT

EDI | ERA/EFT

HIPPA

HIPAA Transactions | HIPAA Code Sets | Unique Identifiers | Privacy of Health Info | HIPAA Security | Contact HIPAA

Drug List

Drug Formulary | Medication Prior Authorization Criteria and Clinical Policies | Physician Administered Preferred Drug List

Policies

Member Rights and Responsibilities | Fraud Prevention Tips | Reimbursement Policies

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