Authorizations

NEW UM PROCESS EFFECTIVE 10/1/24:

Sending sufficient clinical information to support a requested PA is an expectation. Beginning 10/1/24, Molina Healthcare of Iowa asks for clinical information one time if insufficient documentation accompanies the authorization request. If not received within 24 hours, the review will be completed likely leading to a denial.

Please see this Provider Notice for more information.

 

To submit a prior authorization request, please go here: Availity Essentials

 

Utilization Management (UM)

To submit a prior authorization request:

  1. Log in to Availity
  2. Select Patient Registration from the top navigation
  3. Then, select Auth/Referral Inquiry or Authorizations

 

We encourage all providers to start using Availity Essentials for authorizations. To access the authorization tools, you will need an Availity Essentials account. If you are already submitting requests via the portal please complete the following steps to submit for a concurrent review:

1. Go to “Auth Inquiry” OR “Clinical Update.”

2. Enter in the previous authorization number.

3. Attach continued stay clinical documentation.

 

Please note: At this time, you are not required to submit all prior authorization requests using Availity, but we do encourage you to use this method for quicker authorization turnaround times. Molina Iowa UM Fax: (877) 319-6828

 

We use evidence-based clinical practice guidelines when making decision about members’ care.

  • Clinical practice guidelines address preventive, acute or chronic and behavioral health services. These guidelines are reviewed at least every two years and updated as necessary. When this happens, we notify all network practitioners.

    When determining the medical appropriateness of a service, we apply these criteria while taking into account individual circumstances and the local delivery system.

    Clinical and UM staff make decisions based solely on appropriateness of care and existence of coverage. We do not reward staff for issuing denials of coverage. We do not encourage under utilization by providing financial incentives to deny coverage.

    View our Clinical Practice Guidelines here.

 

Member Support Services

Molina Healthcare Member Services is available to help our members if they have any questions about their benefits and services.

  • Member services staff are available Monday through Friday from 8 a.m. to 8 p.m. local time. Members can leave a voice message during non-business hours. We suggest our members leave a voice message with their question if it can wait until the next business day.
  • Molina Healthcare offers free interpreter services to our members. As a provider, you are required to identify the need for interpreter services for your patients who are Molina Healthcare members and offer them appropriate assistance.
  • If members receive care from out-of-network providers without prior authorization, Molina Healthcare will not pay for this care. PCPs should contact us if they wish to request an exception referral for the member to see an out-of-network provider. If an out-of-network provider gives a Molina Healthcare member emergency care, the service will be paid.

 

Visit our Forms page for the most up-to-date list of services requiring prior authorization. Refer to the Molina Healthcare provider manual for more information about prior authorization.