Molina Behavioral Health Prior Authorization Form - Ohio
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3Molina Healthcare of Ohio
Behavioral Health Prior Authorization Form
Phone Number: (800) 642- 4168
Fax Number: (866) 553-9262
Member Information
Plan: ☐ Medicaid ☐ Medicare ☐DUALS ☐Marketplace
Date of Request:_________ Admit Date: __________
Request Type: ☐ Initial ☐ Concurrent
Member Name: ___________________________________________________
DOB: _______________________________
Member ID#: ______________________________________________________
Member Phone: _______________________
Service Is: ☐ Elective/Routine ☐ Expedited/Urgent*
*Definition of Urgent/Expedited service request designation is when the treatment requested is required to prevent serious deterioration in the mem-
ber’s health or could jeopardize the member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/
non-urgent.
Provider Information
Treatment Provider/Facility/Clinic Name and Address: ___________________________________________________________________________
Provider NPI/Provider Tax ID# (number to be submitted with claim): ________________
Attending Psychiatrist Name:__________________________________
UR Contact Name: ________________________________________________
UR Phone#/Fax#: _________________________
Facility Status:
☐PAR
☐Non-PAR
Member Court Ordered?
☐Yes
☐No
☐In Process
Court Date: _______
Service Type Requested
Service is for:
☐ Mental Health
☐ Substance Use
☐ Inpatient Psychiatric Hospitalization
☐ Residential Treatment
☐ Electroconvulsive Therapy (ECT)
☐Involuntary
☐Voluntary
☐ Partial Hospitalization Program
☐ Psychological/Neuropsychological Testing
☐ Day Program
☐ Applied Behavior Analysis
☐ Subacute Detoxification
☐ Non-PAR Outpatient Services
☐Involuntary
☐Voluntary
☐ Other – Describe: __________________
If Involuntary, Court Date: ________________
Procedure Code(s) and Description Requested: _________________________________________________________________________
Length of Stay Requested: ______________________________________________
Dates of Service Requested: _____________________________________________
Primary Diagnosis Code for
Treatment
(including Provisional Diagnosis)
Additional Diagnoses
(including any known Medical
Diagnoses/Conditions)
Psychosocial Barriers
(formerly Axis IV)
For Molina Use Only:
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Behavioral Health Prior Auth Form 2015 – CORP BH Revised 9/4/2014
46180OH1014
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