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
Sc Medicaid Prior Auth Form Education
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 01.01.21Nitro Pro 13 (13.24.1.467)