CurrentMolina HealthcarePolicy N/A

Prior Authorization and Authorization-Related Reimbursement Policy

Governs Molina Healthcare's reimbursement stance and provider guidance for services requiring prior authorization, and addresses claims related to lack of, denied, or incorrect authorization; applies to Molina providers and claims processing.

Policy Summary

PayerMolina Healthcare

PolicyPrior Authorization and Authorization-Related Reimbursement Policy

Policy CodePolicy N/A

Change TypeTemplate updatesinformational

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for services listed in the Molina provider manual; services without authorization will not be reimbursed.

SourceLink

POLICY UPDATE CHANGES

Updated template and added additional links for reference.

Published as a new policy on 06/01/2023.

06/01/2023original publish date

12/17/2024last revised date

state exceptions listedstate exceptions

possiblepost-payment audits

Authorization-Dependent Coverage Criteria

Policy Summary

PayerMolina Healthcare

PolicyPrior Authorization and Authorization-Related Reimbursement Policy

Policy CodePolicy N/A

Change TypeTemplate updatesinformational

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for services listed in the Molina provider manual; services without authorization will not be reimbursed.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Authorization-Dependent Coverage Criteria

Coverage and reimbursement are contingent on prior authorization when required; lack of authorization may result in non-reimbursement and Molina may pursue audits or recovery.

Services requiring prior authorization per the Molina provider manual must have authorization to be reimbursed.

Prior authorization requests are not guarantees of payment; services provided without required authorization will not be reimbursed.

Molina Healthcare reserves the right to conduct post-payment audits for procedures and diagnoses that require authorization.

State-specific exceptions (for example, provisions noted in the State Exceptions section) apply as listed in the policy.

Coding and Billing Requirements

Coding Disclaimermixed

Codes listed are for reference purposes only and may not be all-inclusive. Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement. Listing of a service or device code in this policy does guarantee coverage. Coverage is determined by the benefit document. Molina adheres to Current Procedural Terminology (CPT®), a registered trademark of the American Medical Association (AMA). All CPT codes and descriptions are copyrighted by the AMA; this information is included for informational purposes only. Providers and facilities are expected to utilize industry standard coding practices for all submissions. When improper billing and coding is not followed, Molina has the right to reject/deny the claim and recover claim payment(s). Due to changing industry practices, Molina reserves the right to revise this policy as needed.

Coding accuracy requirement

Expected coding standardProviders and facilities are expected to utilize industry standard coding practices for all submissions.

Consequences of improper codingWhen improper billing and coding is not followed, Molina has the right to reject/deny the claim and recover claim payment(s).

Codes for reference onlyCodes listed in this policy are for reference purposes only and may not be all-inclusive; listing does not guarantee coverage.

Deleted/ineffective codesDeleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.

Authority on coding terminologyMolina adheres to Current Procedural Terminology (CPT®) as maintained by the AMA; CPT codes/descriptions are included for informational purposes only.

Prior Authorization Requirements and Provider Resources

Prior Authorization

Prior Authorization Required

Prior authorization is required for services listed in the Molina provider manual and the state-/program-specific prior authorization guides. Prior authorization requests do not guarantee payment; services provided without required authorization may be denied and Molina reserves the right to conduct post-payment audits and recover payments when authorization requirements are not met. Review your provider manual and contract for authorization billing guidelines.

Prior authorization required for services listed in Molina provider manual and state guide
Prior authorization requests do not guarantee payment; services without authorization may be denied
Molina may perform post-payment audits and recover payments

Note

Where to Find Prior Authorization Forms and Guides

Molina maintains state- and program-specific prior authorization/pre-service review guides, request forms, and PA code matrices on its website. Use the Molina website (www.MolinaHealthcare.com) and navigate to the provider or state-specific pages for: Medicare (PA Lookup Tool, Prior Authorization/Pre-Service Review Guide; general Prior Authorization Request Forms including BH and Pharmacy forms), Marketplace (PA Guide, PA Code Matrix), and individual state Medicaid resources (state prior authorization guides, provider forms, code lists, and specialty forms such as Home Health, Behavioral Health, Pharmacy, Synagis, Advanced Imaging, and medication exception forms). If you cannot find a form for your state or program, contact Molina Provider Services for assistance.

Website: www.MolinaHealthcare.com — Provider > Prior Authorization or state-specific provider pages
Medicare: PA Lookup Tool; Prior Authorization/Pre-Service Review Guide; Prior Authorization Request Forms (medical, BH, pharmacy)
Marketplace: PA Guide and PA Code Matrix (state-specific files)
State Medicaid: state-specific Prior Authorization/Pre-Service Review Guides, PA Code Lists, and request forms (examples include CA, FL, ID, IA, MI, MS, NE, NV, NM, NY, OH, SC, TX, UT, VA, WA, WI)
Common forms: Prior Authorization Request Form, Behavioral Health PA Form, Pharmacy PA Form, Home Health and Outpatient Therapy PA Form, Synagis PA Form, Medication Exception Request Form

Key Definitions

CMS

CMS (definition)Centers for Medicare & Medicaid Services: a federal agency within the U.S. Department of Health and Human Services that administers the Medicare program and works with state governments to manage Medicaid, CHIP, and health insurance portability standards.

Agency contextOperates within the U.S. Department of Health and Human Services.

Authorization (Prior authorization)

Prior authorization (definition)Prior authorization is a requirement that a healthcare provider obtains approval from the insurance plan before prescribing medication or performing a medical procedure.

Provider responsibilityServices requiring prior authorization per Molina provider manuals must have authorization to be reimbursed; Molina may conduct post-payment audits for procedures and diagnoses requiring authorization.