Medical Management Program and Prior Authorization

A. Introduction

Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs. The Molina Healthcare medical management program also ensures that Molina Healthcare only reimburses for services identified as a covered benefit and medically necessary . Elements of the Molina Healthcare medical management program include medical necessity review, prior authorization, inpatient management and restrictions on the use of non-network providers.

B. Medical Necessity Review

In conjunction with regulatory guidance from the Centers for Medicare and Medicaid Services (CMS) and industry standards, Molina Healthcare only reimburses services provided to its members that are medically necessary. Molina Healthcare may conduct a medical necessity review of all requests for authorization and claims, within the specified time frame governed by Federal or State law for all lines of business. This review may take place prospectively, as part of the inpatient admission notification/concurrent review, or retrospectively, as long as the review complies with Federal or State regulations and the Molina Healthcare Hospital or Provider Services Agreement.

Medically Necessary means the care which, in the opinion of the treating physician, is reasonably needed to:

 Prevent the onset or worsening of an illness, condition, or disability;

 Establish a diagnosis;

 Provide palliative, curative, or restorative treatment for physical and/or mental health conditions;

 Assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of same age; and

 Not primarily long-term institutional care services unless long-term institutional services is a Covered Service that the Provider has agreed to provide. In addition, there must be no other effective and more conservative or substantially less costly treatment, service and setting available.

Medically Necessary Services means clinical and rehabilitative physical, mental or behavioral health services that: (i) are essential to prevent, diagnose or treat medical conditions or are essential to enable the Member to attain, maintain or regain the Member’s optimal functional capacity; (ii) are delivered in the amount, duration, scope and setting that are both sufficient and effective to reasonably achieve their purposes and clinically appropriate to the specific physical, and behavioral health care needs of the Member; (iii) are provided within professionally accepted standards of practice and national guidelines; and (iv) are required to meet the physical, and behavioral health needs of the Member and (v) are not primarily for the convenience of the Member, the provider or Molina Healthcare.

The fact that a provider has prescribed, recommended or approved medical or allied goods or services does not, in itself, make such care, goods or services Medically Necessary, a Medical

32 Necessity or a Covered Service/Benefit.

C. Clinical Information

Molina Healthcare requires copies of clinical information be submitted for documentation in all medical necessity determination processes. Clinical information includes but is not limited to; physician emergency department notes, inpatient history/physical exams, discharge summaries, physician progress notes, physician office notes, physician orders, nursing notes, results of laboratory or imaging studies, therapy evaluations and therapist notes. Molina Healthcare does not accept clinical summaries, telephone summaries or inpatient case manager criteria reviews as meeting the clinical information requirements unless required by State regulation or the Molina Healthcare Hospital or Provider Services Agreement.

Molina Healthcare may request specific clinical information such as clinical notes, consultation reports, imaging studies, lab reports, hospital reports, letters of medical necessity and other clinical information deemed relevant. All requested information will be on a need-to-know, minimum, necessary basis.

Molina Healthcare does not require prior authorization for life- threatening, emergency medical or behavioral health conditions.

D. Prior Authorization

Molina Healthcare requires prior authorization for specified services as long as the requirement complies with Federal or State regulations and the Molina Healthcare Hospital or Provider Services Agreement. The list of services that require prior authorization is available in narrative form, along with a more detailed list by CPT and HCPCS codes. Molina Healthcare prior authorization documents are updated annually and the current documents are posted on the Molina Healthcare website. Molina Healthcare has included at the end of this section of this manual a copy of the current Authorization Request form. If using a different form, the prior authorization request must include the following information:

 Member demographic information (name, date of birth, Molina Healthcare ID number, etc.);

 Provider demographic information (referring provider and referred to provider/facility);

 Requested service/procedure, including all appropriate CPT, HCPCS and ICD-9 codes; and

 Clinical information sufficient to document the medical necessity of the requested service.

Services performed without authorization may not be eligible for payment. Services provided emergently (as defined by Federal and State law) are excluded from the prior authorization requirements. Molina Healthcare does not “retroactively” authorize services that require prior authorization.

Molina Healthcare will process any non-urgent requests within fourteen (14) calendar days of receipt of request. Urgent requests will be processed within seventy-two (72) hours.

Providers who request Prior Authorization approval for patient services and/or procedures may 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 provider.

Emergency Services

Emergency services are covered on a (24) hour basis without the need for prior authorization for all Members experiencing an emergency medical situation. Molina Healthcare accomplishes this service by providing Utilization Management during business hours and a (24) hour Nurse Triage option on the main telephone line for post business hours. In addition, the 911 information is given to all members at the onset of any call to the plan.

33 For members within our service area: Molina Healthcare contracts with vendors that provide (24) hour emergency services for ambulance and hospitals. In the event that a Member is outside of the service area, Molina Healthcare is prepared to authorize treatment to ensure that the patient is stabilized.

E. Requesting Prior Authorization

The prior authorization (PA) process requires a request to determine medical necessity/eligibility before the service is rendered. To expedite the review process, pertinent clinical notes (i.e. practitioner office notes, lab test results, etc.) should be attached to the PA request. Authorization for a procedure does not in itself guarantee coverage but notifies you that the procedure as described meets criteria for medical necessity and appropriateness.

1. Practitioners/providers are encouraged to use the Molina Healthcare Web Portal for outpatient prior authorization submission at Web Portal - Provider Self-Serve

There is a rules-based authorization submission process called Clear Coverage. After logging into the Web Portal, choose the drop down option “Create Service Request/Authorization using Clear Coverage” link under the Service Request/Authorization Menu.

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; and

 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.

When using Clear Coverage, practitioners/providers will receive Auto Approval if InterQual Criteria is met for the following:

 Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures;

 Imaging: CT, MRI, MRA, PET, SPECT, Cardiac Nuclear Studies, CT Angiograms, Intimal Media Thickness Testing , Three Dimensional Imaging; and/or

 Genetic Counseling and Testing NOT related to Pregnancy.

If your office/facility would like training to implement the Clear Coverage authorization submission process, please contact your Provider Service Representative.

2. PA Forms and services requiring Prior Authorization can be accessed on the Molina Healthcare website at www.molinahealthcare.com.

a. Choose New Mexico;

b. Choose Health Care Professionals;

c. Forms; and

d. Frequently Used Forms.

Link: 2015 Service Requiring Prior Authorizations Physical Health Prior Authorization Request Form Behavioral Health Prior Authorization Request Form Nursing Facility Level of Care Notification Form

34 3. Prior Authorization Requests may also be submitted by fax via the following Toll Free Fax: (888)

802-5711. Faxes received after 5:00 p.m. Monday through Thursday will be considered to have been received on the next business day. Faxes received after 5:00 p.m. Friday, or on Saturday or Sunday will be considered to have been received on the next business day. Faxes received on a holiday will be considered to have been received on the next business day.

 Medically Urgent Requests by Phone: In Albuquerque: (505) 798-7371 or Toll free (877) 262-0187

 Pharmacy: Toll free fax: (866) 472-4578

4. All authorized services are subject to the Member’s benefit plan and eligibility at the time the service is provided. A list of Molina Healthcare’s services that require prior authorization are listed below. Routine/Elective requests must be faxed to Molina Healthcare.

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