Current (up to 6 months), adequate patient history related to the requested services should be submitted when seeking prior authorization. Examples of information needed include:
Physical examination that addresses the problem Lab or X-ray results to support the request PCP or Specialist progress notes or consultations Any other information or data specific to the request PA Not Required
Returned PA Requests forms marked with “PA Not Required” indicate that prior authorization is not needed for that services. However, this does not mean that service is approved. This is
confirmation of medical necessity only. The authorization is subject to the benefit plan limitations, exclusions and conditions, as well as the member’s eligibility on the date that services are
rendered. This is not an approval for claim payment. Claims will be reviewed for correct coding and edits may be applied.
Web Portal/Clear Coverage
Providers are encouraged to use the Molina Healthcare WebPortal for prior authorization submissions. When submitting a request for outpatient services, Molina has a rules-based
authorization submission process called Clear Coverage. When you log into the WebPortal choose the drop down option “Create Service Request/Authorization using Clear Coverage” link under the Service Request/Authorization Menu. Currently the rules-based authorization submission process is for outpatient services.
Some of the benefits of using Clear Coverage are:
Many outpatient services can automatically be approved at the time of the authorization submission
For requests not automatically approved, you can see the real-time status of your request by opening your office’s home page directly in Clear Coverage
Receive rapid confirmation for services where no authorization is required. You are notified within a few steps if no authorization is required for the CPT code requested. You can print or paste a copy of that notification showing no authorization required for your records. There is no need for you to take any additional action.
Providers can also log into the Molina Healthcare Provider Self Service Portal (ePortal) at
https://eportal.molinahealthcare.com/eportal/providers/login.aspx. (Use of ePortal requires provider
registration).
The Service Request / Authorization page has 4 functionalities:
Service Request / Authorization Status Inquiry
Create Service Request / Authorization
Open an Incomplete Service Request / Authorization
Management
One of the following may be used when searching for Service Request/ Authorization:
Molina Healthcare Member Number
Member Name
Service Request Number
Refer to Provider
Refer from Provider/Facility
The following shows the information required to submit a Service Request/ Authorization:
Patient Information (this information will auto populate with a successful member search)
Service Information
Provider Information
Referring Provider Information
Referred to Provider Information
Additional Provider Access
Rendering Facility Information
Supporting Information Fax
To obtain a prior authorization via fax, please fill out the Prior Authorization Service Request form completely and fax to number located on top of Service request form (Fax # (866) 420- 3639). If you have an urgent request, please mark “URGENT” on the fax. Urgent requests are usually processed within 24-72 hours. If it needs to be processed immediately, please call (866) 449-6849.
115
Management
Authorization Turn-Around Times
TYPE OF REQUEST HHSC – STAR, STAR+PLUS CHIP MMP Non-urgent pre-service decisions Within 3 business days after receipt of request
Within three working days from the date the request is received in writing to the provider of record and the patient or the patient’s representative unless the request is received outside of the period requiring the availability of UM personnel, the determination must be issued and transmitted within three working days from the
beginning of the next time period requiring UM personnel. For determinations concerning an acquired brain injury, in addition to the information outlined above, notification of the determination through a direct telephone contact to the individual making the request is also required.
Within 3 calendar days after receipt of request Urgent pre- service Within 72 clock hours of receipt of request
Within 72 clock hours of receipt of the request
Within 1 business day of receipt of request
subsequent to emergency room treatment
physician or other health care provider within the time
appropriate to the
circumstances
not later than one hour after the time of the request; when denying post- stabilization care requests or life- threatening conditions requests by a treating physician or other health care provider.
the patient's condition, provided that when denying post-stabilization care subsequent to emergency treatment as requested by a treating physician or other health care provider, MHT shall provide the notice to the treating physician or other health care provider not later thanone hour after the time of the request, unless the request is received outside of the period requiring the
availability of appropriate personnel, the determination must be issued and transmitted within one hour from the beginning of the next time period requiring appropriate personnel. Followed by a letter within three working days notifying the patient, the patient’s representative and the provider of record. or other healthcare provider within the time appropriate to the circumstances, not later than one hour after the time of the request for life threatening/ post- stabilization. Urgent concurrent review (i.e. inpatient, ongoing ambulatory services) Within 24 clock hours of receipt of request. Within 24 hrs. of receipt to provider/requestor by
phone or electronic transmission to provider, unless the request is received outside of the period requiring the availability of
appropriate personnel, then within 24 hours of the beginning of the next business day by phone or electronic transmission to provider. Followed by a letter within three working days notifying the patient, or person acting on behalf of the patient and the provider of record of the adverse determination.
Within the NCQA Standard of 24 Clock hours of the receipt of the request
117 notification timelines should be reviewed prior to processing post service decisions unless EMTALA applies)
service decisions unless EMTALA applies) notification timelines should be reviewed prior to processing post service decisions unless EMTALA applies) Definitions:
Pre-Service – A request that must be approved in part or whole in advance of the member obtaining medical care or services. Pre-authorizations and Pre-certifications are pre-service decisions.
Post-Service – Any request for coverage of care of service that a member has already received. Concurrent – Any review for an extension of a previously approved, ongoing course of treatment over a period of time or number of treatments. Concurrent reviews are typically associated with inpatient care or ongoing ambulatory care.
Urgent – Any request for medical care of treatment which could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or in the opinion of the practitioner would subject the member to severe pain that cannot be managed adequately without the care or treatment that is subject of the request.
Non-Urgent – This request will not involve any unnecessary interruption in the member’s treatment for decision-making that may jeopardize the member’s life, health, or ability to recover.
Hospital Admissions
Unplanned admissions require same day (within 24 hours) authorization, or authorization on the next business day if the admission falls on a non-business day. Planned admissions require notification and authorization prior to admission.
Once the complete information is received, Molina Healthcare will process any “non-urgent” requests within three (3) business days. “Urgent” requests will be processed within one (1) business day. Providers who request prior authorization approval for patient services and/or procedures can request to review the criteria used to make the final decision. Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions with the requesting physician at (866) 449-6849.