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Molina Healthcare Prior Authorization Service Request Form

Effective Date: 01/01/2021

Contact: FAX (866) 423-3889 | PHONE (855) 237-6178

MEMBER INFORMATION

Line of Business:[ ] Medicaid[ ] Marketplace[ ] Medicare

State/Health Plan (i.e. CA):

Member Name:

Member ID#:

Service Type:[ ] Non-Urgent/Routine/Elective[ ] Urgent/Expedited - Clinical Reason for Urgency Required[ ] Emergent Inpatient Admission[ ] EPSDT/Special Services

Date of Request:

DOB (MM/DD/YYYY):

Member Phone:

REFERRAL/SERVICE TYPE REQUESTED

Request Type:[ ] Initial Request[ ] Extension / Renewal / AmendmentPrevious Auth#:

Inpatient Services:[ ] Inpatient Hospital[ ] Inpatient Transplant[ ] Inpatient Hospice[ ] Long Term Acute Care (LTAC)[ ] Acute Inpatient Rehabilitation (AIR)[ ] Skilled Nursing Facility (SNF)[ ] Other Inpatient:

Outpatient Services:

[ ] Chiropractic[ ] Dialysis[ ] DME[ ] Genetic/Genomic Testing[ ] Home Health[ ] Hospice[ ] Hyperbaric Therapy[ ] Imaging/Special Tests

[ ] Office Procedures[ ] Infusion Therapy[ ] Laboratory Services[ ] LTSS Services[ ] Occupational Therapy[ ] Outpatient Surgical/Procedures[ ] Pain Management[ ] Palliative Care

[ ] Pharmacy[ ] Physical Therapy[ ] Radiation Therapy[ ] Speech Therapy[ ] Transplant/Gene Therapy[ ] Transportation[ ] Wound Care[ ] Other:

J Code Drug Requests

Include J Code, Drug Name, Dosage, and Frequency

J Code	Drug Name	Dosage	Frequency

[ ] Please send clinical notes and any supporting documentation

Primary ICD-10 Code

Primary ICD-10 Code:

Description:

DATES OF SERVICE

START	STOP	PROCEDURE/ SERVICE CODES	DIAGNOSIS CODE	REQUESTED SERVICE	REQUESTED UNITS/VISITS

PROVIDER INFORMATION

Requesting Provider / Facility

Provider Name:

NPI#:

TIN#:

Phone:

FAX:

Email:

Address:

PCP Name:

PCP Phone:

Office Contact Name:

Office Contact Phone:

Servicing Provider / Facility

Provider/Facility Name (Required):

NPI#:

TIN#:

Phone:

FAX:

Email:

Address:

Medicaid ID# (If Non-Par):

[ ] Non-Par[ ] COC

For Molina Use Only

This section is for internal use by Molina Healthcare.

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.

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