Passport by Molina Healthcare (Passport) follows the most current edition of MCG, a nationally recognized set of guidelines. Passport may employ the Molina Clinical Policies if the MCG guidelines are insufficient. Molina clinical policies are located at www.MolinaClinicalPolicy.com. Please note, these policies do not constitute plan authorization, an explanation of benefits, or a guarantee of payment.
- Tethered Cord Policy Effective Date May 4,2025
- H2027 Psychoeducational Service Effective Date September 1, 2025
- Allogeneic Processed Thymus Tissue Effective Date December 4, 2025
Molina Dental Services Policy Links
- Criteria for Cast Crowns Policy Effective Date January 1, 2026
- Criteria for General Anesthesia and IV Sedation Policy Effective Date January 1, 2026
- Criteria for Fixed Prosthodontics Policy Effective Date January 1, 2026
- Criteria for Occlusal Guards Policy Effective Date January 1, 2026
- Criteria for Maxillofacial Prosthetics Policy Effective Date January 1, 2026
Oncology & Radiology
Passport partners with New Century Health to administer cardiology and oncology services for members age 18+. For clinical policies related to cardiology and oncology, please visit New Century’s website www.NewCenturyHealth.com or click the following link: Compliance and Regulatory Information - New Century Health. Clinical policies are also housed within the provider portal at my.newcenturyhealth.com.
Pharmacy
MedImpact administers pharmacy benefits for Kentucky Medicaid Members. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click here.
Please note that the effective date of any payment policy, and any subsequent revision to a payment policy, shall not be less than 30 days following the date of publication of that revision, pursuant to Section 27.12 of the Kentucky Managed Care Contract.
