Molina Healthcare Of Illinois Prior Authorization Request

Molina Healthcare of Illinois Prior Authorization Request Form

Phone: 1 (855) 866-5462

Medical Authorizations Fax: 1 (866) 617-4971 Advance Imaging Fax: 1 (877) 731-7218

MEMBER INFORMATION

Plan:

Molina Medicaid

Molina Dual Options (Medicaid/Medicare)

Member Name:

DOB:

/

/

Member ID#:

Member Phone#:

(

)

-

Service Type:

Elective/Routine

Expedited/Urgent*

*

Definition: Treatment requested is to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain

maximum function. Treatment requested must be performed within 72 hours.

If request is outside of this definition it should be submitted as Elective/Routine.

Retroactive requests cannot be urgent by definition.

~ Clinical notes and supporting documentation is required to review for medical necessity ~

Referral/Service Type Requested

Inpatient

Home Health

Outpatient

Behavioral Health

Planned Surgical Procedures

Skilled Services

Surgical Procedure

Emergent Admission

ER Admits

Home Infusion

Speech Therapy

PHP(MMP Only)

SNF

Diagnostic Procedure

IOP

DME

Acute Inpatient Rehab

Hyperbaric Therapy

Detox

Wheel Chair (Purchase/Repair)

LTAC

Infusion Therapy

Office Visits

Enteral Formula/Supplies

Custodial SNF

Habilitative Therapy

Prosthetic/Orthotic

Residential

Observation: No PA Required

Radiation Therapy

Other:

ECT

Other

Other

Office Procedure/Visit

Procedure Information

Diagnosis code & Description:

CPT/HCPC Code & Description:

J Code/Description/Dose/NDC:

Number of visits/units requested:

DOS From:

/

/

To:

/

/

If member is diabetic, HgA1c Results within past 6 months:

Treating Physician Information

Name/Credentials:

Contact Name:

Address:

TIN/NPI:

Phone #: (

)

-

Fax #: (

)

-

Treating/Rendering Facility/Provider Information

Name (If other than listed above):

Address:

TIN/NPI:

Phone #: (

)

-

Fax #: (

)

-

By requesting prior authorization, the provider is affirming that the services are medically necessary, a covered benefit under the Medicare and/or Medicaid Program(s), and the servicing provider is enrolled in those programs as eligible for

reimbursement. As a condition of authorization, for services that are primary to Medicare, the out-of-network provider agrees to accept no more than 100% of an amount equivalent to the Medicare Fee-For-Service Program allowable payment rates

(adjusted for place of service or geography) set forth by CMS in effect on the Date(s) of Service, and any portion, if any, that the Medicaid agency or Medicaid managed care plan would have been responsible for paying if the Member was enrolled

in the Medicare Fee-For-Service Program. The Medicare Fee-For-Service Program allowable payment rate deducts any cost sharing amounts, including but not limited to co-payments, deductibles, co-insurance, or amounts paid or to be paid by

other liable third parties that would have been deducted if the Member was enrolled in the Medicare Fee-For-Service Program. If the service is primary to Medicaid, the out-of-network agrees to accept no more than the amount equivalent to the

Medicaid Fee-For-Service Program allowable payment rates set forth by the State of Illinois in effect on the Date(s) of Service, less any applicable Member co-payments, deductibles, co-insurance, or amounts paid or to be paid by other liable third

parties, if any. Molina Healthcare will not reimburse providers for services that are not deemed medically necessary. Servicing providers also recognize that Molina Healthcare members are not to be balanced billed for any uncollected monies for

covered services pursuant to Medicare and Medicaid billing guidelines

For Molina Use Only:

MHIL_2016_PA_Request_Form-Medicaid-Medicare_(Eff_Jan2016)_FNL