Authorization Review (Reimbursement Guidelines)
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Governs Molina Healthcare's reimbursement stance and processes related to prior authorization, denied or incorrect authorization, and provider responsibilities; affects Molina providers submitting claims and prior authorization requests.
No material clinical or coverage changes in this revision.
Authorization and Coverage Criteria
Authorization coverage criteria
Covered when the following authorization requirements and state exceptions are met:
Coding and Billing Codes
| Coding listed for reference only; may not be all-inclusive. Deleted or inactive codes at time of service may not be eligible. Listing of a code does not guarantee coverage. |
Provider Responsibilities and State Exceptions
Prior authorization and billing responsibilities
Providers must follow the authorization billing guidelines in their contract and provider manual. Prior authorization requests do not guarantee payment; services performed without the required authorization will not be reimbursed. Claims submitted outside the proper authorization process are subject to denial or recoupment. Molina may conduct post-payment audits for procedures and diagnoses requiring authorization as outlined in the Molina provider manual.
- Follow authorization billing guidelines in your contract and provider manual.
- Obtain required prior authorization before performing services; lack of authorization can lead to non-reimbursement.
- Claims outside the proper authorization process may be denied or recouped.
- Molina may perform post-payment audits for services requiring authorization.
State exception — Idaho
Idaho exception: prior authorization and referrals are not required when members seek care from participating Molina specialty physicians and providers; prior authorization is required for care from out-of-network specialty physicians and providers.
- In-network participating Molina specialty physicians/providers: no prior authorization or referral required.
- Out-of-network specialty physicians/providers: prior authorization is required.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.