Benefit Information For Molina Healthcare Providers: All Lines of Business
Procedures and Services Services at Non-Par Providers
Hospital Services
Prior Authorization Required
Additional Information
Except for: o Emergency Department Services. o Professional fees associated with
ER visits and approved services. o Local Health Department
Services.
Observation Stays
Clinicals required to review medical
necessity.
Admissions
o Acute Hospital,
o Skilled Nursing Facilities (SNF),
o Rehabilitation Hospital,
o Long Term Acute Care (LTAC)
Facility.
Elective Inpatient Procedures
Transplants/Gene Therapy
Behavioral Health Assessment Behavioral Health Overlay
Therapy Services (Family/Group/Individual)
Medication Assisted Treatment
Psychological Testing
Psychosocial Rehabilitation Services
Specialized Therapeutic Services
Mental Health Targeted Case Management
Clinical updates required for continued length of stay.
Clinical updates required for continued length of stay.
Including Solid Organ and Bone Marrow.
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Statewide Inpatient Psychiatric Program Services
Therapeutic Behavioral On-Site Services
Long Term Care Services (LTC)
Private Duty Nursing
Allergy Testing
Acupuncture
Sleep Studies
Cosmetic, Plastic and Reconstructive
Durable Medical Equipment
Home Healthcare and Home Infusion (Including Home PT, OT or ST)
Occupational Therapy
Except for: o Allergy o Allergy & Immunology o Otolaryngology o Pulmonology
All Places of Service
Please contact:
o Coastal Care Services at: 855-481-0505 for MMA members only.
o Molina Healthcare for LTC and Comprehensive members.
Please contact:
o Coastal Care Services at: 855-481-0505 for MMA members only.
o Molina Healthcare for LTC and Comprehensive members.
For information on services conducted at a Freestanding facility for MMA and
Comprehensive members please contact: o American Therapy Administrators of
Florida (HN1) at: 888-550-8800. o Molina Healthcare for LTC members.
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Physical Therapy
Speech Therapy
Early Intervention Services (Therapy Services)
Radiation Therapy and Radiosurgery
Respiratory Therapy
Experimental/Investigational Procedures
Genetic Counseling and Testing
All Evaluations and Therapies in a Hospital setting require prior authorization from
Molina Healthcare.
For information on services conducted at a Freestanding facility for MMA and
Comprehensive members please contact:
o American Therapy Administrators of Florida (HN1) at: 888-550-8800.
o Molina Healthcare for LTC members.
All Evaluations and Therapies in a Hospital setting require prior authorization from
Molina Healthcare.
For information on services conducted at a Freestanding facility for MMA and
Comprehensive members please contact:
o American Therapy Administrators of Florida (HN1) at: 888-550-8800.
o Molina Healthcare for LTC members.
All Evaluations and Therapies in a Hospital setting require prior authorization from
Molina Healthcare.
Therapy services for EIS members will require Prior Authorization.
Physical Therapy/Occupational Therapy: Required after Initial Evaluation and 24
visits. Speech Therapy (SLP): Required after initial
evaluation.
Except for:
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Healthcare Administered Drugs (oral or
injectable)
Hearing Aids
Housing Assistance
Hyperbaric Therapy
Advanced Imaging, e.g., MRI, CT, PET Scan,
etc.
Lab Services
Massage Therapy
Pet Therapy
Art Therapy
Meals Non-Emergency Day Trips
Post-Discharge Meals
Home Delivered Meals
Non- Emergency Ambulance Services
Nutritional Counseling
Oral Surgery Services
Hospital/Ambulatory Surgery Center (ASC)
Procedures
Pain Management
Prosthetics/Orthotics
o Prenatal diagnosis of congenital disorders of the unborn child through amniocentesis.
o Genetic test screening of newborns mandated by state regulations.
Including anchored hearing aids.
Except for: o Lab Services rendered at Quest
Diagnostics o Services on the Molina In-Office
Labs List (found at: www.Molinahealthcare.com) All Hospital Labs require Prior Authorization.
Disaster Preparedness shelf stable meals
Except for: o Trigger point injections.
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Office visits and office-based procedures
Unlisted & Miscellaneous Codes
Require a referral, but do not require authorization, unless specifically included in another category (i.e.
advanced imaging, lab services) that requires authorization even when
performed in a participating provider's office.
Molina requires standard codes when requesting authorization. Should an
unlisted or miscellaneous code be requested, medical necessity
documentation and pricing must be submitted with the request.
In-Lieu of Services
All services require Prior Authorization:
o Addictions Receiving Facility Services o Ambulatory Detoxification Services o Behavioral Health Services Child Welfare: Must be in the custody of the Department
of Children & Families (DCF) o Community-Based Wrap-Around Services o Crisis Stabilization Units o Drop-In Center Services o Family Training and Counseling for Child o Development o Infant Mental Health Pre/Post Testing Services o Mental Health Partial Hospitalization Program
Services o Mobile Crisis Assessment and Intervention Services o Multi-Systemic Therapy Services o Partial Hospitalization Services o Psychiatric Specialty Hospital Services o Self-Help/Peer Services o Substance Abuse Intensive Outpatient Programs o Substance Abuse Short-Term Residential Treatment Services
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Important Information For Molina Healthcare Providers
Information generally required to support authorization decision making includes:
Current (up to 6 months), adequate patient history related to the requested services. Relevant physical examination that addresses the problem. Relevant lab or radiology results to support the request (including previous MRI, CT Lab
or X-ray report/results). Relevant specialty consultation notes. Any other information or data specific to the request.
Elective/Routine vs Expedited/Urgent
The Urgent / Expedited service request designation should only be used if the treatment is required to prevent serious deterioration in the member's health or could jeopardize the enrollee's ability to regain maximum function. Requests outside of this definition will be handled as routine / non-urgent.
Adverse Determinations Denials
If a request for services is denied, the requesting provider and the member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials are also communicated to the provider by telephone, fax or electronic notification. Verbal, fax, or electronic denials are given within one business day of making the denial decision or sooner if required by the member's condition. Providers and members can request a copy of the criteria used to review requests for medical services. Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions with the requesting physician at 1 (855) 322-4076.
Referrals
Referrals are required for specialist visits and most office-based procedures, except for visits to providers with the following specialties Obstetrics and Gynecology, Dermatology, Chiropractic, and Podiatry. Referrals do not cover office-based procedures that require authorization.
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Important Molina Healthcare Provider Contact Information
Prior Authorizations and Admissions (Including
Long-Term Care Authorizations): Phone: 1 (855) 322-4076 Fax: 1 (866) 440-9791
Provider Customer Service:
Phone: 1 (855) 322-4076 Fax: 1 (562) 499-0719
Transplant Authorizations:
Phone: 1 (855) 714-2415 Fax: 1 (877) 813-1206
24 Hour Nurse Advice Line:
English -
1 (888) 275-8750 TTY: 1 (866) 735-2929 Spanish:
1 (866) 648-3537 TTY: 1 (866) 833-4703
Behavioral Health Authorizations: Beacon Health
Phone: 1 (800) 221-5487 Fax: 1 (617) 747-1230
Transportation: Access2Care Transportation Phone: 1 (888) 278-4781
Pharmacy Authorizations:
Phone: 1 (855) 322-4076 Fax: 1 (866) 236-8531
Vision Care: iCare Solutions Phone: 1 (855) 373-7627
Refer to Molina's Provider website or portal for specific codes that require authorization. https://provider.molinahealthcare.com/Provider/Login
Available Portal features include: *Authorization Submission and Status * Provider Disputes/Appeals * Download Frequently Used Forms * Claims Submission and Status * Member Eligibility * Provider Directory
* Nurse Advice Line Report * Referral Submission and Status
Molina Healthcare of Florida All Lines of Business
Updated: 03/29/2020
Molina Healthcare Prior Authorization/Pre-Service Request Form
Phone Number: 1-855-322-4076
Fax Number: (MMA/LTC/MP) 1-866-440-9791 Fax Number: (MCR) 1-866-472-9509
Plan:
MEMBER INFORMATION
Molina Medicaid (MMA) Medicare (MCR)
Long-Term Care Marketplace (MP)
Member Name:
DOB:
/
/
Member ID#:
Phone: (
)
-
Service Type:
Elective/Routine
Expedited/Urgent*
*Definition of Expedited/Urgent service request designation is when the treatment requested is required to prevent serious deterioration in the member's health or could jeopardize the enrollee's ability to regain maximum function. Requests outside of this
definition should be submitted as routine/non-urgent.
REFERRAL/SERVICE TYPE REQUESTED
Inpatient
Outpatient
Surgical procedures
Surgical Procedure
OT PT ST
Admissions
Diagnostic Procedure Infusion Therapy
SNF
Pain Management
LTAC
Other:
Home Health DME In Office
Diagnosis Code &
Description:
CPT/HCPC/J Code &
Description*:
Strength/Dosage &
Frequency for above J-
Codes**
Number of visits requested:
DOS From:
/
/
to
/
/
Please send clinical notes and any supporting documentation.
*All labs should be sent to a Participating Laboratory
**If multiple CPT or J-Codes, please submit this form along with a separate attachment.
PROVIDER INFORMATION
Requesting Provider Name:
NPI#:
TIN#:
Servicing Provider or Facility:
NPI#:
TIN#:
Contact at Requesting Provider's
office:
Phone Number: (
)
-
Fax Number: (
)
-
For Molina Use Only:
Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member's eligibility, benefit limitation/exclusions, evidence of medical necessity and other applicable standards during the
claim review.