Molina Healthcare Medicaid And Medicare Prior Authorization Request Form

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Molina Healthcare Medicaid and Medicare of New Mexico
Prior Authorization/Pre-Service Review Guide
Effective: 01/01/2015
Molina Healthcare Medicaid and Medicare Prior Authorization Request Form
Medicaid: (877) 262-0187
Toll Free Fax: (888) 802-5711
Medicare: Local Fax: (505) 924-8258
Toll Free Fax: (855) 278-0310
MEMBER INFORMATION
Plan:
Molina Medicaid
Molina Medicare
Other:
Member Name:
DOB:
/
/
Member ID#:
Phone: (
)
-
Service Type:
Elective/Routine
Expedited/Urgent*
*Definition of Urgent / Expedited service request designation is when the treatment
requested 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 should be submitted as routine/non-urgent.
Referral/Service Type Requested
Inpatient
Outpatient
Home Health
Surgical procedures
Surgical Procedure
Rehab (PT, OT, & ST)
ER Admits
Diagnostic Procedure
Chiropractic
DME
SNF
Wound Care
Infusion Therapy
Rehab
Other:
In Office
LTAC
Diagnosis Code & Description:
CPT/HCPC Code & Description:
Number of visits requested:
Date(s) of Service:
Please send clinical notes and any supporting documentation
PROVIDER INFORMATION
Requesting Provider Name:
Facility Providing Service:
Contact at Requesting Provider’s office:
Phone Number: (
)
Fax Number: (
)
For Molina Use Only:
MHNM 2015 Prior Auth Form Medicaid-Medicare (r102314) FINAL (4).docx

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