Prior Authorization and Authorization-Related Reimbursement
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Governs Molina Healthcare's reimbursement stance and procedures related to prior authorization, denied or incorrect authorizations, and post-payment audits; affects Molina providers submitting claims across applicable lines of business.
Updated template and added additional links for reference.
Authorization-dependent Coverage
Authorization-dependent Coverage Criteria
Coverage and payment are contingent on obtaining required prior authorization and following provider manual/contract guidelines.
Provider Requirements and Resources
Authorization and Reimbursement Rule
Prior authorization is required for services as outlined in the Molina provider manual; prior authorization requests do not ensure payment. Services without authorization will not be reimbursed. Molina may conduct post-payment audits for procedures and diagnoses requiring authorization. Providers should refer to their provider manual and contract for proper authorization billing guidelines.
Provider Resources and Forms
Use Molina’s website tools and the listed prior authorization request forms and guides when submitting pre-service review and PA requests. Available resources include the PA Lookup Tool, Prior Authorization/Pre-Service Review Guides, and specific request forms (e.g., Prior Authorization Request Form, Behavioral Health PA Request Form, Pharmacy PA Request Form) as detailed on Molina’s site and state-specific guides.
- PA Lookup Tool and Prior Authorization/Pre-Service Review Guides (state-specific)
- Molina Healthcare, Inc. – Prior Authorization Request Form
- Behavioral Health Prior Authorization Request Form
- Pharmacy Prior Authorization Request Form
- State-specific PA guides and code matrices (examples listed for FL, ID, IL, MI, MS, NM, NV, NE)
State Exceptions Note
State-specific exceptions to prior authorization and reimbursement rules apply; providers must consult the policy’s state exception details for local variations. Examples include Nebraska honoring prior authorizations through March 31, 2024 (with out-of-network claim reimbursement until June 30 and a transplant exception) and Idaho’s variations for specialty care prior authorization and referral requirements.
- NE: Molina of Nebraska will honor prior authorizations through March 31, 2024; out-of-network claims reimbursed until June 30; transplant prior authorizations have a specific requirement.
- ID: Participating Molina specialty physicians/providers do not require prior authorization/referrals; prior authorization is required for nonparticipating specialty providers.
Coding and Billing
| Coding listed in policy is for reference only; listing does not guarantee coverage and deleted/ineffective codes at time of service may not be reimbursable. |
Definitions and Policy Scope
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.