Molina Healthcare/Molina Medicare Authorization Request Form Number: (800) 526-8196 Fax Number: (800) 811-4804 Member Information Plan: Molina Medicaid Molina Medicare Other: Member’s Name: DOB: / / Member’s ID#: Member Phone #: ( ) Service Is: Elective/Routine Expedited/Urgent* *Definition of Urgent / Expedited service request designation is when the treatment requested is required to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent. 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 Office Infusion Therapy ICD-9 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:
Molina Healthcare/Molina Medicare Authorization Request Form Number: (800) 526-8196 Fax Number: (800) 811-4804 Member Information Plan: Molina Medicaid Molina Medicare Other: Member’s Name: DOB: / / Member’s ID#: Member Phone #: ( ) Service Is: Elective/Routine Expedited/Urgent* *Definition of Urgent / Expedited service request designation is when the treatment requested is required to prevent serious deterioration in the member’s health or could jeopardize the enrollee’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/non-urgent. Referral/Service Type Requested Inpatient Surgical procedures ER Admits SNF Rehab LTAC Outpatient Surgical Procedure Rehab (PT, OT, & ST) Diagnostic Procedure Chiropractic Wound Care Infusion Therapy Home Health DME In Office ICD-9 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:
2012%20MHCA%20PA-Pre-Service%20Review%20Guide%20Medicaid-Medicare%20FINAL%201082012.docx