Mlina Healthcare f Puert Ric Prir Authrizatin/Pre-Service Review Guide Effective: 04/01/2015 Use the Mlina web prtal fr faster turnarund times Cntact Prvider Services fr details ***Referrals t Netwrk Specialists and ffice visits t cntracted (par) prviders d nt require Prir Authrizatin*** This Prir Authrizatin/Pre-Service Guide applies t all Mlina Healthcare Medicaid Members Refer t Mlina s website r prtal fr specific cdes that require authrizatin Behaviral Health: Mental Health, Alchl and Chemical Dependency Services: Please refer t cntact infrmatin belw: Inpatient, Partial hspitalizatin Electrcnvulsive Therapy (ECT) Sme Medicatins (including Buprenrphine administratin and treatment) Csmetic, Plastic and Recnstructive Prcedures (in any setting) Dialysis: Please refer t the Mlina s website r prtal fr specific cdes that require authrizatin under the special cverage benefits. DME-nt a cvered benefit, will be determined n a case by case basis. Experimental/Investigatinal Prcedures Genetic Cunseling and Testing except fr prenatal diagnsis f cngenital disrders f the unbrn child thrugh amnicentesis and genetic test screening f newbrns mandated by state regulatins Hspice & Palliative Care: ntificatin nly cvered fr members <21 years nly Hyperbaric Therapy Imaging, Advanced and Specialty Imaging: Refer t Mlina s website r prtal fr specific cdes that require authrizatin Inpatient Admissins: Acute hspital, Rehabilitatin, Hspice (Hspice requires ntificatin nly and is cvered fr members <21 years nly Neurpsychlgical and Psychlgical Testing: Fr Medical Diagnsis nly Nn-Par Prviders/Facilities: Office visits, prcedures, labs, diagnstic studies, inpatient stays except fr: Emergency Department services Prfessinal fees assciated with ER visit, apprved Ambulatry Surgery Center (ASC) r inpatient stay Lcal Health Department (LHD) services Other services based n state requirements Occupatinal Therapy Office-Based Prcedures d nt require authrizatin Outpatient Hspital/Ambulatry Surgery Center (ASC) Prcedures: Refer t Mlina s website r prtal fr specific cdes that require authrizatin Pain Management Prcedures: except trigger pint injectins Physical Therapy Pregnancy and Delivery: ntificatin nly Prsthetics/Orthtics: Refer t Mlina s website r prtal fr specific cdes that require authrizatin Radiatin Therapy and Radisurgery (fr selected services nly): Refer t Mlina s website r prtal fr specific cdes that require authrizatin Rehabilitatin Services: Including Cardiac and Pulmnary, Sleep Studies Speech Therapy Special Cverage Benefits: services cvered under the special benefit cverage may require additinal authrizatin. Please refer t the Mlina s website r prtal fr specific cdes that require authrizatin under the special cverage benefits. Specialty Pharmacy drugs (ral and injectable): Refer t Mlina s website r prtal fr specific cdes that require authrizatin Transprtatin: nn-emergent grund ambulance Transprtatin-nn emergent-nt a cvered benefit, will be determined n a case by case basis. Unlisted, Miscellaneus and T (Temprary) Cdes: Mlina requires standard cdes when requesting authrizatin. Shuld an unlisted r miscellaneus cde be requested, medical necessity dcumentatin and ratinale must be submitted with the prir authrizatin request. Wund Therapy *STERILIZATION NOTE: Federal guidelines require that at least 30 days have passed between the date f the individual s signature n the cnsent frm and the date the sterilizatin was perfrmed. The cnsent frm must be submitted with claim. (Medicaid benefit nly)
IMPORTANT INFORMATION FOR MOLINA HEALTHCARE Infrmatin generally required t supprt authrizatin decisin making includes: Current (up t 6 mnths), adequate patient histry related t the requested services. Relevant physical examinatin that addresses the prblem. Relevant lab r radilgy results t supprt the request (including previus MRI, CT Lab r X-ray reprt/results) Relevant specialty cnsultatin ntes. Any ther infrmatin r data specific t the request. The Urgent / Expedited service request designatin shuld nly be used if the treatment is required t prevent serius deteriratin in the member s health r culd jepardize the enrllee s ability t regain maximum functin. Requests utside f this definitin will be handled as rutine / nn-urgent. If a request fr services is denied, the requesting prvider and the member will receive a letter explaining the reasn fr the denial and additinal infrmatin regarding the grievance and appeals prcess. Denials als are cmmunicated t the prvider by telephne, fax r electrnic ntificatin. Verbal, fax, r electrnic denials are given within ne business day f making the denial decisin, r sner if required by the member s cnditin. Prviders and members can request a cpy f the criteria used t review requests fr medical services. Mlina Healthcare has a full-time Medical Directr available t discuss medical necessity decisins with the requesting physician at (877) 335-3305 Prir Authrizatins: 7:00 a.m. 7:00 p.m. Phne: (888)558-5501 Fax: (855) 378-3641 Imprtant Mlina Healthcare Infrmatin Prvider Custmer Service: 7:00 a.m. 7:00 p.m. Phne: (888)558-5501 Pharmacy Authrizatins: Phne: (888) 558-5501 Fax: (844) 606-7171 Behaviral Health Authrizatins: Phne: (855) 580-2880 Fax: (844) 226-1440 Member Custmer Service Benefits/Eligibility: Phne: (877) 335-3305 TTY/TDD: (787) 522-8281 24 Hur Nurse Advice Line Phne: (888) 620-1515 TTY: (787) 522-8281 Dental: Phne: (866) 622-6120 Fax: (787)749-2900 Transprtatin: Phne: (877) 335-3305 Prviders may utilize Mlina Healthcare s eweb at: www.psgmlinahealthcare.cm
Mlina Healthcare f Puert Ric Prir Authrizatin Request Frm Phne Number: (877) 335-3305 Fax Number: (855) 378-3641 Member Infrmatin Member s Name: DOB: / / Member s ID#: Member Phne #: ( ) Service Is: Elective/Rutine Expedited/Urgent (See Definitin if Selecting) Definitin: Treatment requested is t prevent serius deteriratin in the member s health r culd jepardize the enrllee s ability t regain maximum functin. If request is utside f this definitin it shuld be submitted as Elective/Rutine. *Required Infrmatin t Prcess Request Inpatient Surgical prcedures ER Admits Rehab ICD-9 Cde & Descriptin*: Outpatient Surgical Prcedure PT, OT, & ST Imaging Chirpractic Wund Care Infusin Therapy CPT/HCPC Cde & Descriptin*: Number f visits/services requested*: Name*: Address: Referral/Service Type Requested* Special Cverage Benefit Special Cverage Other Service: Pain Management Pain Management treatment Prcedure Infrmatin DOS*: Ordering/Referring Physician Infrmatin Cntact Name: TIN/NPI*: Phne #*: Fax #*: Name*: Address: Rendering Facility/Prvider Infrmatin TIN/NPI*: Phne #*: Fax #*: Hme Health Skilled Services (SN/PT/OT/ST) Custdial/Supprtive (HHA) Hme Infusin DME Wheel Chair - Purchase/Repair Enteral Frmula/Supplies Prsthetic/Orthtic In Office Prcedure * Clinical ntes and supprting dcumentatin is required t review fr medical necessity* Fr Mlina Use Only:
Pregnancy Ntificatin Frm Thank yu in advance fr cmpleting this frm Please cmplete all sectins and fax within 7 days f the first prenatal visit and/r psitive pregnancy test. Step 1: Cmplete all member infrmatin. DIRECTIONS FOR COMPLETION OF FORM: Tday s Date: / / Step 2: Cmplete the OB/GYN sectin with the name f the OB/GYN t whm the member was referred fr prenatal care. Step 3: Fax frm t Mlina Healthcare f Puert Ric at (855) 378-3641 Step 4: If yu have any questins r need sme assistance, please cntact us at (877) 335-3305 Member s Name: STEP 1: MEMBER INFORMATION Member ID/CIN: Address: City: State: ZIP: Member DOB: / / Phne #: ( ) - Alternate Ph.#: ( ) - Date f Psitive Pregnancy Test: / / Preferred Language: LMP: CURRENT PREGNANCY Hypertensin Diabetes Smking EDC: High Risk Cnditin(s) (if knwn): Excessive Nausea & Vmiting Pre-term labr Multiple Gestatin N prblems with Current Pregnancy Other: OB/GYN Practitiner s Name: PAST PREGNANCY Hypertensin Pre-term labr Diabetes [Original frm t remain in member s chart] N/A Pre-term delivery N prblems with Past Pregnancy Other: STEP 2: OB/GYN INFORMATION OB/GYN Practitiner s Phne Number: ( ) - Date f First Prenatal Appintment: / / Referring Practitiner: Phne: ( ) - STEP 3: FAX FORM TO MOLINA HEALTHCARE Fax t Mlina Healthcare f Puert Ric Fax line at (855) 378-3641 STEP 4: CALL MOLINA WITH QUESTIONS If yu have any questins r need assistance, please cntact us at (877) 335-3305 Thank yu fr taking such gd care f ur members!