Molina Healthcare Prior Authorization Request Form

MEMBER INFORMATION ☐ Molina Medicaid/ ☐ Molina Medicare/ ☐ Molina Medicare/MyCare ☐ Advanced Imaging ☐ Molina MyCare Ohio Opt-Out MyCare Ohio Ohio Opt-In Inpatient Fax: (877) 731-7218 Marketplace Fax: (866) 449-6843 Opt-In Outpatient/ and Home Health Fax: (855) 502-5130 DME (excluding Fax: (877) 708-2116 Home Health) Fax: (844) 251-1450 Member Name: DOB: / / Member ID: Phone: ( ) - Service Type: ☐ Expedited/Urgent* ☐ Elective/Routine *The Expedited/Urgent 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 member’s ability to regain maxi mum function. Requests outside of this definition should be submitted as routine/non-urgent. Please send clinical notes and any supporting documentation PROVIDER INFORMATION Requesting Provider Name & NPI: Facility Providing Service/Facility TIN/NPI: Contact at Requesting Provider’s Office: Phone Number: ( ) Fax Number: ( )

INPATIENT OUTPATIENT Please add codes being requested.

☐ Med/Surgery ☐ Surgical Procedure Respite Services (Medicaid only) ICD-10 Diagnosis ☐ Behavioral Health ☐ Diagnostic Procedure Code & Description: ☐ Medical ☐ Behavioral Health ☐ Behavioral Health

☐ Hospice Non-Par ☐ Hospice Non-Par ☐ OB/GYN ☐ DME CPT/HCPC Code & Description: ☐ Transplant ☐ Home Health

☐ Therapy (PT/OT/ST) ☐ Skilled Nursing ☐ Therapy (Chiropractic) Number of Visits ☐ Acute Rehab ☐ Office Visit Requested: ☐ Long-Term Acute Care (LTAC) ☐ Dialysis Non-Par ☐ Long-Term Care Institutional ☐ Transportation - Custodial Stays (Medicaid only) ☐ Observation Non-Par Date(s) of Service:

☐ Pharmacy

For Molina Healthcare Use Only:

MHO-0709 MolinaHealthcare.com 13382938OH1118 Molina Healthcare Contact Information

Prior Authorizations: 8 a.m. to 6 p.m. Marketplace Member Services: Medicaid/MyCare Ohio Opt-Out: (855) 322-4079 8 a.m. to 7 p.m., Monday to Friday Fax: (866) 449-6843 Phone: (888) 296-7677 Medicare/MyCare Ohio Opt-In: (855) 322-4079 TTY: 711 Inpatient and Home Health Fax: (877) 708-2116 Outpatient Fax (excluding Home Health): (844) 251-1450 Provider Services: Marketplace (855) 322-4079 MyCare Ohio: 8 a.m. to 6 p.m. Fax: (855) 502-5130 All other lines of business: 8 a.m. to 5 p.m. Advanced Imaging Phone: (855) 322-4079 Fax: (877) 731-7218 Fax: (888) 296-7851

Home Health Authorizations: Medicaid/Medicare/Marketplace Medicaid/MyCare Ohio Opt-Out: (855) 322-4079 Fax: (866) 449-6843 24-Hour Nurse Advice Line: Medicare/MyCare Ohio Opt-In: (855) 322-4079 English: (888) 275-8750 Fax: (877) 708-2116 TTY: 711 Marketplace (855) 322-4079 Spanish: (866) 648-3537 Fax: (855) 502-5130 TTY: 711

Radiology Authorizations: MyCare Ohio 24-Hour Nurse Advice Line: Phone: (855) 714-2415 English & Spanish: (855) 895-9986 Fax: (877) 731-7218 TTY: 711

Pharmacy Authorizations: Vision Care: Medicaid: (855) 322-4079 Phone: (855) 322-4079 Fax: (800) 961-5160 Fax: (888) 493-4070 Medicare: (855) 322-4079 Fax: (866) 290-1309 Dental: Phone: (855) 322-4079 Medicaid Member Services: Provider Web Portal: www.sciondental.com 7 a.m. to 7 p.m., Monday to Friday Phone: (800) 642-4168 Transportation: For Members TTY: 711 Medicaid: (866) 642-9279 MyCare Ohio: (844) 491-4761 MyCare Ohio Member Services: 8 a.m. to 8 p.m., Monday to Friday Providers may use Molina Healthcare’s Provider Web Portal at: Molina Dual Options (opt-in): (855) 665-4623 www.MolinaHealthcare.com/OhioProviders Molina MyCare Ohio Medicaid (opt-out): (855) 687-7862 Available features include: TTY: 711 • Authorization submission and status • Frequently used forms Medicare Member Services: • Claims submissions and status • Member eligibility 8 a.m. to 8 p.m., seven days a week • Provider directory Phone: (866) 472-4584 • Nurse Advice Line TTY: 711

MolinaHealthcare.com Medicaid, Medicare and MyCare Ohio Prior Authorization/Pre-Service Review Guide Prior Authorization requests are also accepted on the Provider Web Portal. Referrals to network specialists and office visits to contracted (par) providers do not require prior authorization. This prior authorization/pre-service guide applies to all Molina Healthcare Medicaid, Medicare and MyCare Ohio members; it excludes Marketplace. Refer to Molina Healthcare’s PA Code List for specific codes that require authorization at www.MolinaHealthcare.com/OhioProviders under the “Forms” tab. Only covered services are eligible for reimbursement. • Behavioral health: Mental health, alcohol and chemical • Radiation therapy and radiosurgery (for selected services dependency services: only): Refer to Molina Healthcare’s website or Web Portal for • ACT specific codes that require authorization • IHBT • Rehabilitation services: Including cardiac, pulmonary and • CPST comprehensive outpatient rehabilitation facility (CORF). CORF • Psychological Testing services for Medicare only. • SBIRT • Home health care and home infusion: • Alcohol or Drug Assessment • Medicare/MMP Medicare after initial evaluation plus 2 • Psychiatric Diagnostic Evaluations Inpatient, residential treatment, visits per calendar year partial hospitalization • Marketplace/Medicaid/MMP Medicad after initial evaluation • Electroconvulsive therapy (ECT) plus 6 visits per calendar year. Note: Fax to Inpatient line, • Applied behavioral analysis (ABA) – for treatment of Autism as listed on previous page. spectrum disorder (ASD) • Hyperbaric therapy • Cosmetic, plastic and reconstructive procedures (in any setting) • Imaging, advanced and specialty imaging: Refer to Molina • Dental general anesthesia: Greater than 7 years old or per state Healthcare’s website or Web Portal for specific codes that benefit (not a Medicare-covered benefit) require authorization • Durable medical equipment: Refer to Molina Healthcare’s website or • Inpatient admissions: acute hospital, skilled nursing facilities Web Portal for specific codes that require authorization (SNF), rehabilitation, long-term acute care (LTAC) facility • Medicare hearing supplemental benefit: contact Avesis at • Inpatient hospice and palliative care (800) 327-4462 • Long-term services and supports: Per state benefit. Refer to • Experimental/investigational procedures (in any setting) Molina Healthcare’s website or Provider Web Portal for specific • Genetic counseling and testing except for prenatal diagnosis of codes that require authorization. Not a Medicare-covered benefit. congenital disorders of the unborn child through amniocentesis and • Neuropsychological and psychological testing genetic test screening of newborns mandated by state regulations • Non-par providers/facilities- office visits, procedures, • Occupational therapy: labs, diagnostic studies, inpatient stays except for: • Marketplace/Medicare/MMP Medicare PA required after 24 dates • Emergency department services of service • Professional fees associated with emergency department • Medicaid/MMP Medicaid Ohio PA required after 30 dates of service visit, approved • Office-based procedures do not require authorization (unless • Ambulatory surgery center (ASC) or inpatient stay otherwise noted) • Other services based on state requirements • Outpatient hospital/ambulatory surgery center (ASC) procedures: • Respite care Refer to Molina Healthcare’s website or Web Portal for specific codes • Sleep studies that require authorization • Specialty pharmacy drugs (oral and injectable): Refer to • Pain management procedures (in any setting): Except trigger point Molina Healthcare’s website or Web Portal for specific codes injections (acupuncture is not a Medicare-covered benefit) that require authorization • Physical therapy: • Speech therapy: After initial evaluation plus 30 visits for • Marketplace/Medicare/MMP Medicare PA required after 24 outpatient setting dates of service • Transplants including solid organ and bone marrow • Medicaid/MMP Medicaid Ohio PA required after 30 dates • Transportation: Non-emergent ambulance air transport of service • Unlisted, miscellaneous and T (temporary) codes (in any • Pregnancy and delivery setting): Molina Healthcare requires standard codes when • Prosthetics/orthotics: Refer to Molina Healthcare’s website or Web requesting authorization. Should an unlisted or miscellaneous Portal for specific codes that require authorization code be requested, medical necessity documentation and rationale must be submitted with the prior authorization request. • Wound therapy *STERILIZATION NOTE: Federal guidelines require that at least 30 days have passed between the date of the individual’s signature on the consent form and the date the sterilization was performed. The consent form must be submitted with claim. (Medicaid benefit only)

MolinaHealthcare.com IMPORTANT INFORMATION FROM MOLINA HEALTHCARE OF OHIO Information generally required to support authorization decision making includes: • Current (up to six 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 Expedited/Urgent 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 (when applicable) 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/fax or electronic notification. Verbal and fax denials are given the same day of the denial decision.

Post-Stabilization Services: Effective 06/01/2014—Molina Healthcare provides post-stabilization services for Medicare members and MyCare Ohio dual eligible members. If you are a non-contracted provider and need authorization for post- stabilization services after normal business hours, please call our 24-Hour Nurse Advice Line. • Medicare – English: (888) 275-8750 (TTY 711) • Medicare – Spanish: (866) 648-3537 (TTY: 711) • MyCare Ohio English/Spanish: (855) 895-9986 (TTY: 711) • Includes 24-Hour Behavioral Health Crisis Line

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