Molina Healthcare/molina Medicare Prior Authorization Request Form

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Molina Healthcare/Molina Medicare Prior Authorization Request Form
Phone Number: (888) 483-0760
Medicaid/CHIP Fax Number: (866) 472-0589
Medicare Fax Number: (866) 504-7262
Member Information
Plan:
Molina Medicaid/CHIP
Molina Medicare
Other:
Member’s Name:
DOB:
/
/
Member’s ID#:
Member Phone #: (
)
______
Service Is:
Elective/Routine
Expedited/Urgent (See Definition if Selecting)
Definition: Treatment requested is to prevent serious deterioration in the member’s health or could
jeopardize the enrollee’s ability to regain maximum function.
If request is outside of this definition it should be submitted as Elective/Routine.
*Required Information to Process Request
*
Referral/Service Type Requested
Inpatient
Outpatient
Mental Health
Home Health
Surgical procedures
Surgical Procedure
Inpatient
Skilled Services (SN/PT/OT/ST)
ER Admits
PT, OT, & ST
PHP
Custodial/Supportive (HHA)
SNF
Imaging
IOP
Home Infusion
Rehab
Chiropractic
Chemical Dependency
DME
LTAC
Wound Care
Office Visits
Wheel Chair - Purchase/Repair
Infusion Therapy
Enteral Formula/Supplies
Prosthetic/Orthotic
In Office Procedure
Procedure Information
*
ICD-9 Code & Description
:
*
CPT/HCPC Code & Description
:
*
*
Number of visits requested
:
DOS
:
Ordering/Referring Physician Information
Contact Name:
*
Name
:
Address:
*
*
*
TIN/NPI
:
Phone #
:
Fax #
:
Rendering Facility/Provider Information
*
Name
:
Address:
*
*
*
TIN/NPI
:
Phone #
:
Fax #
:
* Clinical notes and supporting documentation is required to review for medical necessity*
For Molina Use Only:

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