Molina Prior Authorization Form PDF Details

In today’s intricate healthcare system, the Molina Prior Authorization Request Form plays a pivotal role in ensuring that Molina Healthcare members receive the necessary medical services while maintaining compliance with their health plan requirements. This form, essential for members in Bexar, Harris, Dallas, Jefferson, El Paso, and Hidalgo Service Areas, as well as in the CHIP Rural Service Area, acts as a gateway for various healthcare services ranging from routine elective procedures to urgent medical care that requires immediate attention. It meticulously records essential information such as the member’s plan type—whether it's Molina Medicaid, Medicare, TANF, or other—alongside personal details, including the member's name, date of birth, and member ID. The form distinguishes between elective/routine and expedited/urgent services, with the latter being defined by situations where any delay could seriously jeopardize the member's health or ability to regain maximum function. It encompasses a broad spectrum of medical services requests, including but not limited to inpatient and outpatient services, home health care, surgical procedures, diagnostic procedures, and therapies. Additionally, it mandates the inclusion of diagnosis and procedure codes, the number of visits requested, and the specific dates of service to facilitate a comprehensive review process. Provider information is also integral to the form, ensuring clear communication channels between Molina Healthcare and the healthcare professional or facility requesting authorization. The thorough compilation of this information underscores the form’s importance in bridging member care needs with policy compliance, underscoring the critical nature of prior authorization in the healthcare system.

QuestionAnswer
Form NameMolina Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmolina pa form, molina prior auth form, molina prior authorization, molina prior authorization form

Form Preview Example

Molina Healthcare Prior Authorization Request Form

Phone Number: 1-866-449-6849 (Bexar, Harris, Dallas, Jeferson, El Paso & Hidalgo Service Areas) 1-877-319-6826 (CHIP Rural Service Area)

Fax Number: 1-866-420-3639

Member Information

Plan: ☐ Molina Medicaid ☐ Molina Medicare ☐ TANF ☐ Other

Member’s Name: _______________________________________________________ DOB: _________________________________

Member’s ID#: _________________________________________________________ Member Phone #: _______________________

Service Is: ☐ Elective/ Routine ☐ Expedited/Urgent*

*Deinition of expedited/urgent is when the situation where the standard time frame or decision making process (up to 14 days per Molina’s process) could seriously jeopardize the life or health of the enrollee, or could jeopardize the enrollee’s ability to regain maximum function.

Referral/Service Type Requested

Inpatient

Outpatient

☐ Home Health

☐ Surgical procedures

☐ Surgical Procedure

 

☐ ER Admits

☐ Rehab (PT, OT, & ST)

 

 

☐ SNF

☐ Diagnostic Procedure

☐ DME

☐ Rehab

☐ Chiropractic

 

 

☐ LTAC

☐ Wound Care

☐ In Oice

 

☐ Infusion herapy

 

 

 

 

 

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 @ Requesting Provider’s: _________________________________________________________________________________

Phone Number: __________________________________________ Fax Number: _________________________________________

For Molina Use Only:

8992TX1011

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Filling out segment 1 in molina pa form pdf

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