The prior authorization (PA) process requires a written 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.
Practitioners/providers are encouraged to use the Molina Healthcare Web Portal for prior authorization submission. When submitting a request for outpatient services, 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. Clear Coverage is for outpatient services.
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.
PA Forms and services requiring Prior Authorization based upon r egulatory and contractual requirements can be accessed on the Molina Healthcare website at www.molinahealthcare.com
1. Choose New Mexico;
2. For Health Care Professionals;
3. Forms; and
4. “Frequently Used Forms.”
Prior Authorization Requests may be submitted via the following:
Molina Healthcare Web Portal (including Clear Coverage):
Web Portal - Provider Self-Serve
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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 t he next business day.) Prior Authorization Request Forms are located on the Molina Healthcare Provider Website at www.molinahealthcare.com
1. Choose New Mexico;
2. For Health Care Professionals;
3. Forms; and
4. “Frequently Used Forms.”
Medically Urgent Requests
In Albuquerque: (505) 798-7371 or Toll free (877) 262-0187
Pharmacy
Toll free fax: (866) 472-4578
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 of New Mexico, Inc. (Molina Healthcare) services that require prior authorization are listed below. Routine/Elective requests must be faxed to Molina Healthcare for all Physical Health requests.
The Prior Authorization/Pre-Service Guide applies to all Molina Healthcare
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This Prior Authorization/Pre-Service Guide applies to all Molina Healthcare/Molina Medicare Members.
***Referrals to Network Specialists do not require Prior Authorization***
Authorization required for services listed below.
Pre-Service Review is required for elective services.
Only covered services will be paid
Behavioral Health: Mental Health, Alcohol and Chemical Dependency Services: Refer to Behavioral Health on page 2.
Chiropractic Services*
Cosmetic, Plastic and Reconstructive Procedures in any setting:
which are not usually covered benefits include but are not limited to tattoo removal, collagen injections, rhinoplasty, otoplasty, scar revision, keloid treatments, and surgical repair of gynecomastia, pectus deformity, mammoplasty, abdominoplasty, venous injections, vein ligation, venous ablation or dermabrasion, botox injections, etc.
Dental General Anesthesia: > 7 years old or per state benefit (Not a Medicare covered benefit)
Dialysis: notification only
Diapers (not a Medicare covered benefit), Incontinence products Durable Medical Equipment/Medical
Supplies/Orthotics/Prosthetics:
Refer to Molina’s website for specific codes that require authorization.
Medicare Hearing Supplemental benefit: Contact Avesis at 800-327-4462
Experimental/Investigational Procedures
Genetic Counseling and Testing except for prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by state regulations Home Healthcare: after 3 skilled nursing visits
Home Infusion
Outpatient Hospice & Palliative Care: notification only.
Imaging: CT, MRI, MRA, PET, SPECT, Cardiac Nuclear Studies, CT Angiograms, intimal media thickness testing, three dimensional (3D) imaging
Inpatient Admissions: Acute hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility, Hospice (Hospice requires notification only)
LTC Services (per state benefit): Refer to Long Term Care Services on page 2. Not a Medicare covered benefit.
Neuropsychological and Psychological Testing and Therapy Non-Par providers/Facilities: office visits, procedures, labs, diagnostic studies, inpatient stays except for:
o Emergency Department Services
o Professional fees associated with ER visits, approved Ambulatory Surgery Center (ASC) or inpatient stay o Women’s Health, Family Planning and Obstetrical Services o Child and Adolescent Health Center Services
o Local Health Department (LHD) services o Other services based on state requirements.
Nutritional Supplements & Enteral Formulas Occupational Therapy (outpatient and home settings)
o Under 21 years: After initial evaluation plus 6 visits o 21 years and older: After initial evaluation
Office-Based Surgical Procedures do not require auth except for Podiatry Surgical Procedures (excluding routine foot care)
Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures: Refer to Molina’s website for specific codes that are EXCLUDED from authorization requirements Pain Management Procedures: including
sympathectomies, neurotomies, injections, infusions, blocks, pumps or implants, and acupuncture (Not a Medicare covered benefit)
Physical Therapy (outpatient and home settings) o Under 21 years: After initial evaluation plus 6 visits o 21 years and older: After initial evaluation
Pregnancy and Delivery: notification only Rehabilitation: Cardiac Rehabilitation, Pulmonary Rehabilitation, and CORF (Comprehensive Outpatient Rehab Facility) services for Medicare only
Sleep Studies
Specialty Pharmacy drugs (oral and injectable) used to treat the following disease states, including but not limited to: Anemia, Crohn’s/Ulcerative Colitis, Cystic Fibrosis, Growth Hormone Deficiency, Hemophilia, Hepatitis C, Immune Deficiencies, Multiple Sclerosis, Oncology, Psoriasis, Pulmonary Hypertension, Rheumatoid Arthritis, and RSV prophylaxis (Refer to Molina’s website for specific codes that require
authorization)
Speech Therapy (outpatient and home settings)
o Under 21 years: After initial evaluation plus 6 visits o 21 years and older: After initial evaluation
Transplant Evaluation and Services: including solid organ and bone marrow (except Cornea transplants) Transportation: non-emergent ground and air ambulance Unlisted CPT and miscellaneous codes Molina requires standard codes when requesting authorization. Should an unlisted or miscellaneous code be requested, medical necessity documentation and rationale must be submitted with the prior authorization request.
Weight Watchers Meetings
Wound Therapy including Wound Vacs and Hyperbaric Wound Therapy
*Medicare covered service ONLY.
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This Prior Authorization/Pre-Service Guide applies to all Molina Healthcare/Molina Medicare Members.
***Referrals to Network Specialists do not require Prior Authorization***
Authorization required for services listed below.
Pre-Service Review is required for elective services.
Only covered services will be paid
Office Visits (after 20 during a 12 month period – Medicare only for PA requirements)*
Office Visits (after 20 during a 12 month period – Medicare only for PA requirements)*
Partial Hospitalization (Medicare only for PA requirements)*
*Medicare covered services as well as Medicaid covered services.
**Medicare covered service ONLY.
Long Term Care*
Enhanced Adaptive Aids (Dual eligible members only) Meals on Wheels (Dual eligible members only) Nursing Facility (custodial care)
Reintegration Services (Dual eligible members only)
Agency-Based Community Benefit: the following services can be provided within the member’s Individual Service Plan
Adult Day Health
Self-Directed Community Benefit: the following services can be provided within the member’s Service & Support Plan
Behavior Support consultation
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IMPORTANT INFORMATION FOR MOLINA HEALTHCARE/MOLINA MEDICARE Information generally required to support authorization decision making includes:
• Current (up to 6 months), adequate patient history related to the requested services.
• Relevant physical examination that addresses the problem.
• Relevant lab or radiology results to support the request (including previous MRI, CT Lab or X-ray report/results)
• Relevant specialty consultation notes.
• Any other information or data specific to the request.
The Urgent / Expedited service request designation should only be used if the treatment is required to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain maximum function. Requests outside of this definition will be handled as routine / non-urgent.
• If a request for services is denied, the requesting provider and the member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials also are communicated to the provider by telephone or fax. Verbal and fax denials are given within one business day of making the denial decision, or sooner if required by the member’s condition.
• Providers can request a copy of the criteria used to review requests for medical services.
• Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions with the requesting physician at 1 (800) 377-9594.
Important Molina Healthcare/Molina Medicare Information Monday through Friday 8:00 AM to 5:00 MT
Prior Authorizations:
Medicaid: 1 (877) 262-0187 Fax: 1 (888) 802-5711 Medicare: 1 (888) 825-9266 Fax: 1 (888) 802-5711
Pharmacy Authorizations:
Medicaid: 1 (800) 580-2811 Fax: 1 (866) 472-4578
Medicare: 1 (866) 440-0127 Fax: 1 (866) 450-3914
Behavioral Health Authorizations:
Medicare: 1 (888) 660-7185 Fax: 1 (888) 802-5711
Member Customer Service Benefits/Eligibility:
Medicaid: 1 (800) 580-2811 Fax: 1 (505) 342-0595 Medicare: 1 (866) 440-0127 Fax: 1 (801) 858-0409 TTY/TDD: 1 (800)346-4128
Provider Customer Service: 8:00 am – 5:00 pm (M-F) Phone: 1 (888) 825-9266 Fax: 1 (505) 342-4711 24 Hour Nurse Advice Line
English: 1 (888) 275-8750 [TTY: 1 (866) 735-2929]
Spanish: 1 (866) 648-3537 [TTY: 1 (866) 833-4703]
Vision Care: March Vision Services Phone: 1 (888) 493-4070 Hearing Exam Benefits: Medicare (Avesis):
Phone: 1 (800) 327-4462 Dental:
Phone: 1 (800) 580-2811 (Medicaid) Phone: 1 (855) 214-6779 (Medicare-Avesis) Transportation (Medicaid/ITM):
Phone: 1 (888) 593-2052
Transportation Medicare (Logisticare):
Phone: 1 (866) 475-5423 (Reservations) Phone: 1 (866) 474) 5331(Ride Assist)
Providers may utilize Molina Healthcare’s Web Portal at: www.molinahealthcare.com Available features include:
• Authorization submission and status
• Claims submission and status (EDI only)
• Download Frequently used forms
• Member Eligibility
• Provider Directory
• Nurse Advice Line Report
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Criteria Used in Making Medically Necessary Decisions – Physical Health
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 Molina Healthcare Quality Assurance Committee (QAC) has approved several criteria sets to be utilized for review of service requests. Molina Healthcare utilizes the Office of Disability Guidelines, and internally developed Medical Coverage Guidance Documents to determine appropriateness of service requests.
InterQual Smart Sheets are specifically created to guide the provider through the clinical criteria and are available upon request. A copy of other specific guidelines can be requested by contacting the Health Care Services (HCS) Department or your Provider Service Representative.
If the requested services do not meet criteria for medical necessity or covered services, the case will be referred to a physician reviewer for determination. Utilization review criteria, internal guidelines, and nationally recognized criteria are used to determine approval of the requested service authorization.
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. A ll 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.
Molina Healthcare employs physicians licensed in the State of New Mexico to make medical necessity denial decisions for Centennial Care Members. Board certified physicians from appropriate specialty areas will provide consultations as needed for medical necessity decisions.
Denial decisions are communicated to the provider and the Member, in writing, as required by contract and NCQA standards. These letters include the specific utilization review criteria or benefits provisions used in the determination and provide information on the appeal process.
Providers have telephonic access to the Medical Director to discuss medical necessity determinations.
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Behavioral Health Level of Care Guidelines
ACUTE INPATIENT HOSPTILIZATION
I. DEFINITION OF SERVICE:
Acute Inpatient Psychiatric Hospitalization is a twenty-four (24)-hour secure and protected, medically staffed, psychiatrically supervised treatment service. T his level of care is for stabilization of urgent or emergent behavioral health problems. Acute Inpatient Hospitalization is provided specifically for those consumers who, as a result of a psychiatric disorder, are an acute and significant danger to themselves or others, or are acutely and significantly disabled, or whose activities of daily living are significantly impaired. T his level of care involves the highest level of skilled psychiatric services. It is rendered in a freestanding psychiatric hospital or the psychiatric unit of a general hospital. The care must be provided under the direction of an attending physician who performs a face-to-face interview of the consumer within 24 hours of admission. The care involves an individualized treatment plan that is reviewed and revised frequently based on the consumer’s clinical status.
This level of care should not be authorized solely as a substitute for management within the adult corrections, juvenile justice or protective services systems, as an alternative to specialized schooling (which should be provided by the local school system), or simply to serve as respite or housing.
This level of care is available for all age ranges, but admission should be to a unit that is age appropriate. For school age children and youth, academic schooling funded through the local school system or by the facility is expected.
II. ADMISSION CRITERIA (meets A and B, and C or D, or E or F):
Medical necessity has been demonstrated according to the New Mexico Medical Assistance Division definition contained in NMAC 8.305.1, a nd the consumer has a DSM diagnosed condition that requires, and is likely to benefit from, therapeutic intervention;
Treatment cannot safely be administered in a less restrictive level of care;
There is an indication of actual or potential imminent danger to self which cannot be controlled outside of a twenty-four (24)-hour treatment setting. Examples of indications include serious suicidal ideation or attempts, severe mutilation or other serious self-destructive actions.
There is an indication of actual or potential imminent danger to others and the impulses to harm others cannot be controlled outside of a twenty-four (24)-hour treatment setting.
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An example of an indication includes a current threat and means to kill or injure someone;
There is disordered or bizarre thinking, psychomotor agitation or retardation, and/or a loss of impulse control or impairment in judgment leading to behaviors that place the consumer or others in imminent danger. These behaviors cannot be controlled outside of a twenty-four (24)-hour treatment setting; and/or
There is a co-existing medical illness that complicates the psychiatric illness or treatment. Together the illnesses or treatment pose a high risk of harm for the consumer, and cannot be managed outside of a twenty-four (24)-hour treatment setting.
III. CONTINUED STAY CRITERIA (meets all):
The consumer continues to meet admission criteria.;
An individualized treatment plan that addresses the consumer’s specific symptoms and behaviors that required Inpatient treatment has been developed, implemented and updated, with the consumer’s and/or guardian’s participation whenever possible, which includes consideration of all applicable and appropriate treatment modalities; and
An individualized discharge plan has been developed which includes specific realistic, objective and measurable discharge criteria and plans for appropriate follow-up care. A timeline for expected implementation and completion is in place but discharge criteria have not yet been met.
IV. DISCHARGE CRITERIA (meets all):
The consumer has met his/her individualized discharge criteria;
The consumer can be safely treated at a less intensive level of care; and
An individualized discharge plan with appropriate, realistic and timely follow-up care is in place.
V. EXCLUSIONARY CRITERIA (may meet any):
The condition of primary clinical concern is one of a medical nature (not behavioral health) and, as outlined in the current Mixed Services Protocol, should be covered by another managed care entity; and/or
The consumer appears to have presented for admission for reasons other than a primary psychiatric emergency, such as homelessness or in appropriate seeking of medications.
Waiting Placement Days (DAP) Rate
I. DESCRIPTION:
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Per NMAC 8.311.2.14 (4.MAD 721.5) and NMAC 8312.2 (742.14.A-C) Inpatient Days awaiting Placement (DAP) is a negotiated rate used when a Medicaid eligible consumer no longer meets acute care criteria and it is verified that the eligible consumer requires a residential level of care which may not be immediately located, those days during which the eligible consumer is awaiting placement to the lower level of care are termed “awaiting placement days”.. T hese circumstances must be beyond the control of the inpatient provider. DAP is intended to be brief and to support transition to the lower level of care. DAP may not be used solely because the inpatient provider did not pursue or implement a discharge plan in a timely manner.
II. Approval Criteria (must meet all):
The consumer is covered by Medicaid as administered by the Medical Assistance Division definition, and the consumer has a DSM diagnosed condition that has required an acute inpatient psychiatric level of care currently;
The consumer no longer meets continued stay criteria for inpatient acute psychiatric care and/or does meet discharge criteria and there is a specific discharge plan in place to a residential level of care, but documented barriers to implementation of that plan exist that are beyond the control of the provider or facility;
The provider has made reasonable efforts to identify and obtain the services needed to implement the discharge plan, and continues to actively work to identify resources to implement that plan; and
The MCO has authorized the residential level of care sought as the discharge, and documentation of this authorization has been made available to MCO utilization management personnel.
II. Exclusionary Criteria:
The consumer has met his/her individualized discharge criteria and substantial barriers to discharge no longer exist;
The inpatient facility cannot demonstrate that it continues to actively work to eliminate barriers to the planned discharge; and
The inpatient facility is pursuing a discharge to a level of care or service that a MCO psychiatrist peer reviewer has explicitly stated does not appear to meet admission criteria at this time.
23 Hour Observation Stay
I. DEFINITION OF SERVICE:
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A twenty-three (23) Hour Observation Stay occurs in a s ecure, medically staffed, psychiatrically supervised facility. This level of care, like acute inpatient hospitalization, involves the highest level of skilled psychiatric services. T his service can be rendered in a psychiatric unit of a general hospital, or in the emergency department of a licensed hospital.
The care must be provided under the direction of an attending physician who has performed a face-to-face evaluation of the consumer. The care involves an individual treatment plan that includes access to the full spectrum of psychiatric services. A twenty-three (23) Hour Observation Stay provides an opportunity to evaluate consumers whose needed level of care is not readily apparent. In addition, it may be used to stabilize a consumer in crisis, when it is anticipated that the consumer’s symptoms will resolve in less than twenty-four (24) hours.
This level of care may be considered when support systems and/or a previously developed crisis plan have not sufficiently succeeded in stabilizing the consumer, and the likelihood for further deterioration is high. This level of care is available for all age ranges.
If a physician orders an eligible recipient to remain in the hospital for less than twenty-four (24) hours, the stay is not covered as inpatient admission, but is classified as an observation stay. An observation stay is considered an outpatient service.
The following are exemptions to the general observation stay definition:
The eligible recipient dies;
Documentation in medical records indicates that the eligible recipient left against medical advice or was removed from the facility by his legal guardian against medical advice;
An eligible recipient is transferred to another facility to obtain necessary medical care
An eligible recipient is transferred to another facility to obtain necessary medical care