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Free Michigan Molina Prior Authorization Template in PDF

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The Michigan Molina Prior Authorization form serves as a critical tool for healthcare providers seeking approval for various medical services and treatments under Molina Healthcare. This form is designed to streamline the process for obtaining necessary authorizations, whether for Medicaid or Medicare members. It requires essential information, including the member's name, ID number, and contact details, along with specifics about the requested service type—be it inpatient, outpatient, surgical procedures, or home health care. The distinction between elective and urgent requests is crucial; urgent requests must meet strict criteria to prevent serious health deterioration. Providers must also include diagnosis and procedure codes, as well as the number of visits requested and relevant dates of service. Additionally, the form mandates the submission of clinical notes and supporting documentation to facilitate the review process. Clear communication is key, as the form includes sections for both member and provider information, ensuring that all necessary parties are informed and involved in the authorization process.

Form Example

Molina Healthcare of Michigan Prior Authorization Request Form

Phone Number: (888) 898-7969

Medicaid Fax Number: (800) 594-7404

Medicare Fax: (888) 295-7665

Member I nformat ion

Plan:

Molina Medicaid

Member Name:

Molina MI Child

Molina Medicare

DOB:

Other:

Member I D# :

 

Member Phone # :

(

)

Service I s:

Elective/ Routine

Expedited/ Urgent *

*Definition of Urgent / Expedited service request designation is w hen the treat ment requested is required to prevent serious deterioration in the member’s health or could jeopardize the member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/ non- urgent.

Referral/ Service Type Request ed

 

I npatient

 

 

 

 

 

 

Outpatient

 

 

 

 

Surgical Procedures

 

 

 

 

 

 

Surgical Procedure

 

DME

 

 

ED Admission

 

 

 

 

 

 

Rehab (PT, OT, & ST)

 

 

 

 

Direct Admission

 

 

 

 

 

 

Diagnostic Procedure

 

 

 

 

SNF

 

 

 

 

 

 

I maging

 

Home Health

 

 

Rehab

 

 

 

 

 

 

Chiropractic

 

 

 

 

LTAC

 

 

 

 

 

 

Wound Care

 

 

 

 

 

 

 

 

 

 

 

 

I nfusion Therapy

 

I n Office

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referred To Provider/ Facility Name & Tax I D# : _____

 

 

 

 

Referred To Address & Phone# :

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis Code & Description:

 

 

 

 

 

 

 

 

 

 

 

 

CPT/ HCPCS Code & Description:

 

 

 

 

 

 

 

 

 

 

 

 

Number of visits requested:

 

 

 

 

 

Date(s) of Service:

 

 

 

 

 

Please send clinical not es and any support ing document at ion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider I nformat ion

 

 

 

 

Requesting Provider Name and Address:

 

 

 

 

Contact @ Requesting Provider’s:

 

 

 

 

 

 

 

 

 

 

 

Phone Number: (

)

 

 

 

 

 

 

 

 

Fax Number: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Molina Use Only:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2013 MI Molina Healthcare/ Molina Medicare PA GUI DE 5/ 8/ 13

▼ Michigan Molina Prior Authorization PDF Form

Document Specs

Fact Name Description
Contact Information The Molina Healthcare of Michigan Prior Authorization form includes a phone number: (888) 898-7969. Fax numbers are also provided for Medicaid and Medicare submissions.
Member Information Members must provide their plan type, name, date of birth, ID number, and phone number on the form.
Service Type Requests can be made for various service types, including inpatient, outpatient, surgical procedures, and home health services.
Urgent vs. Routine The form distinguishes between urgent and routine requests. Urgent requests are for services that prevent serious health deterioration.
Provider Information Requesting providers must include their name, address, phone number, and fax number on the form.
Diagnosis and Procedure Codes Providers need to fill in the diagnosis code and description, as well as the CPT/HCPCS code and description for the requested service.
Supporting Documentation Clinical notes and any supporting documents must be sent along with the prior authorization request for review.
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