Providers

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)

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  

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