Utilization Management (UM) Program
Molina’s UM Department is designed to provide comprehensive health care management by managing utilization services and benefits effectively and efficiently.
UM Decision Making
Molina follows a hierarchy of medical necessity decision-making, with federal and state regulations taking precedence. The following medical necessity criteria are used and available to contracted providers:
- Applicable federal or state mandates and guidelines as required
- American Society of Addiction Medicine (ASAM)
- Molina WA Merge Criteria - Molina Apple Health (Medicaid) prior authorization (PA) criteria which includes Health Care Authority (HCA) guidance on certain procedures
- Molina WA Pharmacy Criteria - Policies and guidelines intended to be a resource for relevant information about drugs, treatment and coverage
- Molina Clinical Policy (MCP) - Corporate guidance documents addressing new or existing technology
- MCG care guidelines (secure provider portal)
Providers can contact Molina at (855) 322-4082 to obtain criteria used to make a final determination.
Helpful Web Addresses
- MCPs with Washington-specific addendums can be found on the Washington Medicaid - Molina Clinical Policy (MCP) page.
- A comprehensive list of corporate MCPs can be found at MolinaClinicalPolicy.com.
- PA forms are available on the Frequently Used Forms page.
- Log in to Molina’s Provider Portal via OneHealthPort or the legacy login page.
- Providers may also access the Molina Provider Portal for additional clinical criteria (e.g., MCG care guidelines) and PA information.
- Information regarding Sepsis Guidelines.
- Molina uses the revised sepsis guidelines issued by the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) for all product lines.
- For additional information, please see: The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Singer, M., Deutschman, C. S., et al. JAMA 2016; 315(8):801-810.
Contact UM Staff
Providers can contact us at our toll-free number (800) 869-7185 between 8 a.m. and 5 p.m. PST, Monday - Friday. We are available to discuss any utilization management requirements, processes or procedures.
Peer-to-Peer Discussion and Reconsideration ProcessFor Apple Health (Medicaid) or Marketplace members:
In the case of adverse determination, the requesting provider has the option to submit a Reconsideration request or schedule a Peer-to-Peer discussion with a Molina Medical Director within the time frames listed below, in order to avoid the appeals process. Pursuing these options is appropriate when there is additional information or context not provided in the clinical information that may result in an approval.Peer-to-Peer:
- May be requested within 3 business days from adverse benefit determination (denial) notification (written or fax notification), or at any time during an inpatient admission;
- May not be requested if a formal appeal has been filed;
- May not be requested when no clinical information was submitted and the denial was based on lack of information. In this case, please follow the Reconsideration pathway. Submitting clinical information with a Reconsideration request may result in an approval or a revised denial that would come with new Peer-to-Peer and Reconsideration timeframes;
- Time period to request a Peer-to-Peer: 3 business days.
Reconsideration by the UM Department:
- May be requested within 14 calendar days from adverse benefit determination (denial) notification (written or fax notification);
- May be requested if new clinical information is available that was not previously submitted at the time of the initial denial determination;
- May be requested if no clinical information was submitted and the denial was based on lack of information;
- May be requested following discharge from an inpatient level of care;
- May be requested if provider is unable to request a Peer-to-Peer discussion within 3 business days after the adverse benefit determination (denial) notification;
- Reconsideration cannot be requested following a Peer-to-Peer discussion. In this case, please follow appeal pathway for further dispute rights;
- Time period to request a Reconsideration: 14 calendar days.
Scheduling a Peer-to-Peer
Please call (425) 398-2603 to request and schedule a Peer-to-Peer discussion or if you have questions regarding the Peer-to-Peer or Reconsideration process. Peer-to-Peer discussions will be scheduled Monday through Friday from 9 a.m. to 4 p.m. PST, excluding holidays. For Advance Imaging (AI) authorizations, please call (855) 714-2415 (enter 92 for WA). A Molina Medical Director will call you at your scheduled date and time, at the direct number provided.
When scheduling a Peer-to-Peer, you will be asked to provide:
- Member name, date of birth, and Molina ID number, if available
- The authorization request the provider would like to discuss
- New clinical information to be faxed for review prior to the Peer-to-Peer
- Direct contact number for the provider (not a pager)
NOTE: Peer-to-Peer discussions will not be scheduled if a formal member appeal has already been filed. Peer-to-Peer discussions are for medical necessity denials, not administrative denials.