Molina Healthcare is advising our providers of a critical outage of our third-party vendor Optum-Change Healthcare (CHC), resulting in impacts to: Electronic Claims Submission, Payment, and Settlement Services.
Learn MoreScreening Criteria
This page contains the Molina internal screening criteria for preauthorization
The files below are in PDF format ()
Molina Clinical Review: 3D Interpretation and Reporting of Imaging Studies
Download Molina Clinical Review: 3D Interpretation and Reporting of Imaging StudiesMolina Clinical Review: Abdomen CTA with runoff
Download Molina Clinical Review: Abdomen CTA with runoffMolina Clinical Policy: Ambulatory and Video EEG Monitoring Outpatient Setting
Download Molina Clinical Policy: Ambulatory and Video EEG Monitoring Outpatient SettingMolina Clinical Policy: Artificial Disc Replacement
Download Molina Clinical Policy: Artificial Disc ReplacementMolina Clinical Policy: Autologous Chondrocyte Implantation Knee
Download Molina Clinical Policy: Autologous Chondrocyte Implantation KneeMolina Clinical Policy: Balloon Sinus Ostial Dilation (Balloon Sinuplasty)
Download Molina Clinical Policy: Balloon Sinus Ostial Dilation (Balloon Sinuplasty)Molina Clinical Policy: Bioimpedence Analysis for Lymphedema Assessment
Download Molina Clinical Policy: Bioimpedence Analysis for Lymphedema AssessmentMolina Clinical Policy: Bioness Foot Drop System
Download Molina Clinical Policy: Bioness Foot Drop SystemMolina Clinical Review: Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair
Download Molina Clinical Review: Blepharoplasty, Blepharoptosis, and Brow Ptosis RepairMolina Clinical Policy: Breast Implant Removal
Download Molina Clinical Policy: Breast Implant RemovalMolina Clinical Policy: Bronchial Thermoplasty
Download Molina Clinical Policy: Bronchial ThermoplastyMolina Clinical Policy: Category III CPT Codes
Download Molina Clinical Policy: Category III CPT CodesMolina Clinical Policy: Clinical Trials and Rare Disease Policy
Download Molina Clinical Policy: Clinical Trials and Rare Disease PolicyMolina Clinical Policy: Computer Aided Evaluation Malignancy Breast with MRI and Lung Radiology
Download Molina Clinical Policy: Computer Aided Evaluation Malignancy Breast with MRI and Lung RadiologyMolina Clinical Policy: COVID-19 Co-Pays and Cost Share
Download Molina Clinical Policy: COVID-19 Co-Pays and Cost ShareMolina Clinical Policy: Cranial Orthotic Devices
Download Molina Clinical Policy: Cranial Orthotic DevicesMolina Clinical Review: CT (Computer Tomography) Heart with 3D Image
Download Molina Clinical Review: CT (Computer Tomography) Heart with 3D ImageMolina Clinical Review: CT Heart Calcium Scoring
Download Molina Clinical Review: CT Heart Calcium ScoringMolina Clinical Policy: Deep Brain Stimulation for Epilepsy
Download Molina Clinical Policy: Deep Brain Stimulation for EpilepsyMolina Clinical Review: Diagnostic CT Colonography
Download Molina Clinical Review: Diagnostic CT ColonographyMolina Clinical Policy: Donor Lymphocyte Infusion
Download Molina Clinical Policy: Donor Lymphocyte InfusionMolina Clinical Policy: Electric Tumor Treatment Fields for Glioblastoma
Download Molina Clinical Policy: Electric Tumor Treatment Fields for GlioblastomaMolina Clinical Policy: EPAP for Obstructive Sleep Apnea
Download Molina Clinical Policy: EPAP for Obstructive Sleep ApneaMolina Clinical Review: Epidural Steroid Injections for Chronic Back Pain
Download Molina Clinical Review: Epidural Steroid Injections for Chronic Back PainMolina Clinical Policy: Evaluation of New Technology UM 10
Download Molina Clinical Policy: Evaluation of New Technology UM 10Molina Clinical Policy: Experimental and Investigational Services
Download Molina Clinical Policy: Experimental and Investigational ServicesMolina Clinical Review: Facet Joint Diagnostic Injections for Chronic Back Pain
Download Molina Clinical Review: Facet Joint Diagnostic Injections for Chronic Back PainMolina Clinical Policy: Functional Electrical Stimulation for Spinal Cord Injury
Download Molina Clinical Policy: Functional Electrical Stimulation for Spinal Cord InjuryMolina Clinical Policy: Gastroesophageal Reflux Disease GERD Treatment
Download Molina Clinical Policy: Gastroesophageal Reflux Disease GERD TreatmentMolina Clinical Policy: Gastrointestinal Electrical Stimulation _GES for Obesity
Download Molina Clinical Policy: Gastrointestinal Electrical Stimulation _GES for ObesityMolina Clinical Policy: Genicular RFA for Chronic Knee Pain
Download Molina Clinical Policy: Genicular RFA for Chronic Knee PainMolina Clinical Policy: Heart Transplantation
Download Molina Clinical Policy: Heart TransplantationMolina Clinical Policy: Heart Transplantation with a Total Artificial Heart
Download Molina Clinical Policy: Heart Transplantation with a Total Artificial HeartMolina Clinical Policy: Hematopoietic Stem Cell Transplantation Aplastic Anemia
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Aplastic AnemiaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation Ewing's Sarcoma
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Ewing's SarcomaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic LeukemiaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Myelogenous Leukemia
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Acute Myelogenous LeukemiaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Germ Cell TumorsMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Immunodeficiency Disorders
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Immunodeficiency DisordersMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for MPS
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for MPSMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes _MDS
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndromes _MDSMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Neuroblastoma
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for NeuroblastomaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Primary MyelofibrosisMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Sickle Cell Anemia
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Sickle Cell AnemiaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation for Wilm's Tumor
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation for Wilm's TumorMolina Clinical Policy: Hematopoietic Stem Cell Transplantation Hodgkins and NonHodgkins Lymphoma
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Hodgkins and NonHodgkins LymphomaMolina Clinical Policy: Hematopoietic Stem Cell Transplantation Multiple Myeloma
Download Molina Clinical Policy: Hematopoietic Stem Cell Transplantation Multiple MyelomaMolina Clinical Policy: High Intensity Focused Ultrasound for Prostate CA
Download Molina Clinical Policy: High Intensity Focused Ultrasound for Prostate CAMolina Clinical Review: Hyperbaric Oxygen Therapy
Download Molina Clinical Review: Hyperbaric Oxygen TherapyMolina Clinical Policy: IDEO (Intrepid Dynamic Exoskeletal Orthosis) for Lower Extremity Injuries
Download Molina Clinical Policy: IDEO (Intrepid Dynamic Exoskeletal Orthosis) for Lower Extremity InjuriesMolina Clinical Policy: iFuse Implant for Sacroiliac Joint Fusion
Download Molina Clinical Policy: iFuse Implant for Sacroiliac Joint FusionMolina Clinical Policy: Implantable Neurostimulator for Central Sleep Apnea
Download Molina Clinical Policy: Implantable Neurostimulator for Central Sleep ApneaMolina Clinical Policy: Implantable Neurostimulator for Urinary and Fecal Incontinence
Download Molina Clinical Policy: Implantable Neurostimulator for Urinary and Fecal IncontinenceMolina Clinical Policy: Implanted Intrathecal Pain Pumps Chronic Pain
Download Molina Clinical Policy: Implanted Intrathecal Pain Pumps Chronic PainMolina Clinical Policy: Inhaled Nitric Oxide _iNO for Neonatal Hypoxic Respiratory Failure
Download Molina Clinical Policy: Inhaled Nitric Oxide _iNO for Neonatal Hypoxic Respiratory FailureMolina Clinical Policy: Intensity Modulated Radiation Therapy _IMRT
Download Molina Clinical Policy: Intensity Modulated Radiation Therapy _IMRTMolina Clinical Policy: Interspinous Decompression Devices for Spinal Stenosis
Download Molina Clinical Policy: Interspinous Decompression Devices for Spinal StenosisMolina Clinical Policy: Interspinous Process Fixation Devices for Spinal Fusion
Download Molina Clinical Policy: Interspinous Process Fixation Devices for Spinal FusionMolina Clinical Policy: Intervertebral Stabilization Devices
Download Molina Clinical Policy: Intervertebral Stabilization DevicesMolina Clinical Policy: Ketogenic Diet for Treatment of Intractable Seizures
Download Molina Clinical Policy: Ketogenic Diet for Treatment of Intractable SeizuresMolina Clinical Policy: Kidney Transplantation
Download Molina Clinical Policy: Kidney TransplantationMolina Clinical Policy: Kymriah _tisagenlecleucel Chimeric Antigen Receptor T cell Therapy
Download Molina Clinical Policy: Kymriah _tisagenlecleucel Chimeric Antigen Receptor T cell TherapyMolina Clinical Policy: Liver Transplantation Adult Pediatric
Download Molina Clinical Policy: Liver Transplantation Adult PediatricMolina Clinical Review: Low Dose CT Scan for Lung Cancer Screening
Download Molina Clinical Review: Low Dose CT Scan for Lung Cancer ScreeningMolina Clinical Policy: Lower Limb Robotic Exoskeleton _ReWalk for Parapalegia
Download Molina Clinical Policy: Lower Limb Robotic Exoskeleton _ReWalk for ParapalegiaMolina Clinical Policy: Magnetic Resonance Guided Focused Ultrasound _MRgFUS for Essential Tremor
Download Molina Clinical Policy: Magnetic Resonance Guided Focused Ultrasound _MRgFUS for Essential TremorMolina Clinical Review: Magnetic Resonance Neurography
Download Molina Clinical Review: Magnetic Resonance NeurographyMolina Clinical Review: Magnetic Resonance Spectroscopy
Download Molina Clinical Review: Magnetic Resonance SpectroscopyMolina Clinical Policy: Measurement of Carotid Artery Intima Thickness
Download Molina Clinical Policy: Measurement of Carotid Artery Intima ThicknessMolina Clinical Policy: Monarch Trigeminal Nerve Stimulation (eTNS) System
Download Molina Clinical Policy: Monarch Trigeminal Nerve Stimulation (eTNS) SystemMolina Clinical Review: MRA Angiography Brain
Download Molina Clinical Review: MRA Angiography BrainMolina Clinical Review: MRI Angiography Spinal Canal
Download Molina Clinical Review: MRI Angiography Spinal CanalMolina Clinical Review: MRI Temporomandibular Joint _TMJ
Download Molina Clinical Review: MRI Temporomandibular Joint _TMJMolina Clinical Policy: MyoPro Orthosis _Myomo, Inc. for Upper Extremity Paralysis/Paresis
Download Molina Clinical Policy: MyoPro Orthosis _Myomo, Inc. for Upper Extremity Paralysis/ParesisMolina Clinical Policy: Noninvasive Positive Pressure Ventilation
Download Molina Clinical Policy: Noninvasive Positive Pressure VentilationMolina Clinical Policy: Noninvasive Prenatal Testing
Download Molina Clinical Policy: Noninvasive Prenatal TestingMolina Clinical Policy: Occipital Nerve Block for Treatment of Migraine Headache
Download Molina Clinical Policy: Occipital Nerve Block for Treatment of Migraine HeadacheMolina Clinical Policy: Optical Coherence Tomography (OCT) of the Anterior Eye Segment
Download Molina Clinical Policy: Optical Coherence Tomography (OCT) of the Anterior Eye SegmentMolina Clinical Review: Oral and Tube Fed Enteral Nutrition
Download Molina Clinical Review: Oral and Tube Fed Enteral NutritionMolina Clinical Review: Orbit-Sella-Neck-Temporal Bone IAC including Mastoid-Posterior Fossa MRI
Download Molina Clinical Review: Orbit-Sella-Neck-Temporal Bone IAC including Mastoid-Posterior Fossa MRIMolina Clinical Review: Orbit-Sella-Temporal Bone IAC Mastoid-Posterior Fossa CT
Download Molina Clinical Review: Orbit-Sella-Temporal Bone IAC Mastoid-Posterior Fossa CTMolina Clinical Policy: Pancreas Transplant Procedures
Download Molina Clinical Policy: Pancreas Transplant ProceduresMolina Clinical Policy: Pediatric Bariatric Surgery
Download Molina Clinical Policy: Pediatric Bariatric SurgeryMolina Clinical Policy: Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz Procedure
Download Molina Clinical Policy: Percutaneous Epidural Adhesiolysis for Chronic Low Back Pain Racz ProcedureMolina Clinical Policy: Percutaneous Ventricular Assist Devices
Download Molina Clinical Policy: Percutaneous Ventricular Assist DevicesMolina Clinical Policy: Peroral endoscopic myotomy (POEM) for Esophageal Achalasiac
Download Molina Clinical Policy: Peroral endoscopic myotomy (POEM) for Esophageal AchalasiaMolina Clinical Review: PET Scan Heart _Cardiac
Download Molina Clinical Review: PET Scan Heart _CardiacMolina Clinical Review: PET Scan With or Without CT Attenuation
Download Molina Clinical Review: PET Scan With or Without CT AttenuationMolina Clinical Review: Phototherapy and Laser Therapy for Dermatological Conditions
Download Molina Clinical Review: Phototherapy and Laser Therapy for Dermatological ConditionsMolina Clinical Policy: Plantar Fasciitis Treatment
Download Molina Clinical Policy: Plantar Fasciitis TreatmentMolina Clinical Policy: Plasmapheresis for Renal and Nonrenal Indications
Download Molina Clinical Policy: Plasmapheresis for Renal and Nonrenal IndicationsMolina Clinical Policy: Platelet Enriched Plasma
Download Molina Clinical Policy: Platelet Enriched PlasmaMolina Clinical Policy: Pretransplant Evaluation
Download Molina Clinical Policy: Pretransplant EvaluationMolina Clinical Policy: Prialt (ziconotide intrathecal infusion)
Download Molina Clinical Policy: Prialt (ziconotide intrathecal infusion)Molina Clinical Policy: Prostatic Urethral Lift or UroLift for BPH
Download Molina Clinical Policy: Prostatic Urethral Lift or UroLift for BPHMolina Clinical Policy: Proton Beam Radiation Therapy
Download Molina Clinical Policy: Proton Beam Radiation TherapyMolina Clinical Policy: QEEG for ADHD with NEBA System
Download Molina Clinical Policy: QEEG for ADHD with NEBA SystemMolina Clinical Policy: Radioactive Microspheres for Liver Cancer
Download Molina Clinical Policy: Radioactive Microspheres for Liver CancerMolina Clinical Review: Radiofrequency Ablation for chronic back pain
Download Molina Clinical Review: Radiofrequency Ablation for chronic back painMolina Clinical Policy: Radiofrequency Ablation (RFA) of Primary or Metastatic Liver Tumors
Download Molina Clinical Policy: Radiofrequency Ablation (RFA) of Primary or Metastatic Liver TumorsMolina Clinical Policy: Recombinant Human Bone Morphogenetic Protein
Download Molina Clinical Policy: Recombinant Human Bone Morphogenetic ProteinMolina Clinical Policy: Renal Autotransplantation
Download Molina Clinical Policy: Renal AutotransplantationMolina Clinical Review: Sacroiliac Injections and RFA for SIJ Pain
Download Molina Clinical Review: Sacroiliac Injections and RFA for SIJ PainMolina Clinical Policy: Salpingectomy for Female Sterilization
Download Molina Clinical Policy: Salpingectomy for Female SterilizationMolina Clinical Review: Screening CT Colonography
Download Molina Clinical Review: Screening CT ColonographyMolina Clinical Policy: Shoulder Arthroscopy Guidelines
Download Molina Clinical Policy: Shoulder Arthroscopy GuidelinesMolina Clinical Policy: Skin Substitutes for Chronic Wound Healing in the Out-Patient Setting
Download Molina Clinical Policy: Skin Substitutes for Chronic Wound Healing in the Out-Patient SettingMolina Clinical Policy: Small Bowel Multivisceral Transplantation
Download Molina Clinical Policy: Small Bowel Multivisceral TransplantationMolina Clinical Policy: Smart Watch for Detection of AF
Download Molina Clinical Policy: Smart Watch for Detection of AFMolina Clinical Policy: Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
Download Molina Clinical Policy: Stereotactic RadiosurgeryMolina Clinical Policy: Thermography and BSGI Imaging for the Detection of Breast Lesions
Download Molina Clinical Policy: Thermography and BSGI Imaging for the Detection of Breast LesionsMolina Clinical Policy: Transarterial Chemoembolization for Primary Liver Hepatocellular Cancer
Download Molina Clinical Policy: Transarterial Chemoembolization for Primary Liver Hepatocellular CancerMolina Clinical Policy: Transcatheter Aortic Valve Replacment
Download Molina Clinical Policy: Transcatheter Aortic Valve ReplacmentMolina Clinical Policy: Transcatheter Pulmonary Valve Replacement Melody
Download Molina Clinical Policy: Transcatheter Pulmonary Valve Replacement MelodyMolina Clinical Policy: Triangle Tilt Mod Quad Surgery for Brachial Plexus Injury
Download Molina Clinical Policy: Triangle Tilt Mod Quad Surgery for Brachial Plexus InjuryMolina Clinical Review: Vagal Nerve Stimulation
Download Molina Clinical Review: Vagal Nerve StimulationMolina Clinical Policy: Vagus Nerve Stimulation for Depression
Download Molina Clinical Policy: Vagus Nerve Stimulation for DepressionMolina Clinical Policy: Virtual Bronchoscopy for Pulmonary Lesions
Download Molina Clinical Policy: Virtual Bronchoscopy for Pulmonary LesionsMolina Clinical Policy: Water Vapor Thermal Therapy for BPH (formerly Rezum System for BPH)
Download Molina Clinical Policy: Water Vapor Thermal Therapy for BPH (formerly Rezum System for BPH)Molina Clinical Policy: XEN Glaucoma Treatment System
Download Molina Clinical Policy: XEN Glaucoma Treatment SystemVisit Forms & Documents, download what you need when you need it.