Molia Healthcare, Inc. - Prior Authorization Service Request Form

Prior Authorization Service Request Form Molina Healthcare

Prior, Authorization, Service, Request, Form, Molina, Healthcare

Molina Healthcare

Molia Healthcare, Inc. - Prior Authorization Service ...

Molina Healthcare, Inc. – Prior Authorization Service Request Form E FFECTIVE: 01/01/2021 FAX (866) 423-3889 PHONE (855) 237-6178 . Molina Healthcare of South Carolina, Inc. 2021 Prior Authorization Guide/Request Form

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Molina® Healthcare, Inc. ­ Prior Authorization Service Request Form
EFFECTIVE: 01/01/2021
FAX (866) 423-3889 PHONE (855) 237-6178
MEMBER INFORMATION

Line of Business:  Medicaid  Marketplace

 Medicare

Date of Request:

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

Member Name:

DOB (MM/DD/YYYY):

Member ID#:

Member Phone:

Service Type:

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

Request Type:

 Initial Request

Inpatient Services:

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

REFERRAL/SERVICE TYPE REQUESTED

 Extension/ Renewal / Amendment Previous Auth#:

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: J Code: J Code: J Code:

Primary ICD-10 Code:

DATES OF SERVICE

START

STOP

J Code Drug Requests (Include J Code, Drug Name, Dosage, and Frequency)

Drug Name:

Dosage:

Frequency:

Drug Name:

Dosage:

Frequency:

Drug Name:

Dosage:

Frequency:

Drug Name:

Dosage:

Frequency:

Please send clinical notes and any supporting documentation

Description:

PROCEDURE/ SERVICE CODES

DIAGNOSIS CODE

REQUESTED SERVICE

REQUESTED UNITS/VISITS

REQUESTING PROVIDER / FACILITY:

Provider Name:

Phone:

Address:

PCP Name:

Office Contact Name:

SERVICING PROVIDER / FACILITY:

Provider/Facility Name (Required):

NPI#:

TIN#:

Phone:

Address:

For Molina Use Only:

PROVIDER INFORMATION

NPI#:

TIN#:

FAX:

Email:

City:

State:

Zip:

PCP Phone:

Office Contact Phone:

FAX:

Medicaid ID# (If Non-Par): City:

Email:

State:

Non-Par COC Zip:

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.

Molina Healthcare of South Carolina, Inc.

2021 Prior Authorization Guide/Request Form Effective 01.01.21