MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018

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MOLINA HEALTHCARE MEDICARE PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 01/01/2018 FOR MMP MEDICAID, PLEASE REFER TO YOUR STATE MEDICAID PA GUIDE FOR ADDITIONAL PA REQUIREMENTS Refer to Molina s Provider Website/Portal for specific codes that require authorization ONLY COVERED SERVICES ARE ELIGIBLE FOR REIMBURSEMENT OFFICE VISITS TO CONTRACTED/PARTICIPATING PRIMARY CARE PROVIDERS DO NOT REQUIRE PA. OFFICE VISITS TO NETWORK SPECIALISTS REQUIRE A REFERRAL FROM A PARTICIPATING PRIMARY CARE PROVIDER. EMERGENCY SERVICES DO NOT REQUIRE PRIOR AUTHORIZATION. ALL NON-PAR PROVIDER REQUESTS REQUIRE AUTHORIZATION REGARDLESS OF SERVICE. : Mental Health, Alcohol and Chemical Dependency s: o Inpatient, Partial Hospitalization; o Electroconvulsive Therapy (ECT). Cosmetic, Plastic and Reconstructive Procedures (in any setting) Durable Medical Equipment o Medicare Hearing Aides [supplemental benefit]. Contact AVESIS at 1 (800) 327-4462. Experimental/Investigational Procedures Genetic Counseling and Testing except for prenatal diagnosis of congenital disorders of the unborn child through amniocentesis and genetic test screening of newborns mandated by state regulations. Home health care and Home infusion, including Home PT, OT and ST: After initial evaluation plus six (6) visits per calendar year. Effective 3/1/2018 All home health care services require PA after initial evaluation. Hyperbaric Therapy Imaging, Advanced and Specialty Imaging Inpatient Admissions: Elective, Acute hospital, Skilled Nursing Facilities (SNF), Rehabilitation, Long Term Acute Care (LTAC) Facility. Long Term s and Supports: Not a Medicare covered benefit*. (*Per State benefit if MMP) Neuropsychological and Psychological Testing Non-Par Providers/Facilities: Office visits, procedures, labs, diagnostic studies, inpatient stays except for: o Emergency Department s; o Professional fees associated with ER visit and approved Ambulatory Surgery Center (ASC) or inpatient stay; o Local Health Department (LHD) services; o Other services based on State Requirements. Occupational & Physical Therapy: After Medicare therapy benefit cap has been reached for office and outpatient settings. Office-Based Procedures do not require authorization, unless specifically included in another category (i.e. advanced imaging) that requires authorization even when performed in a participating provider s office Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures Pain Management Procedures: except trigger point injections (Acupuncture is not a Medicare covered benefit). Prosthetics/Orthotics Radiation Therapy and Radiosurgery (for selected services only) Sleep Studies: (Except Home sleep studies) Specialty Pharmacy drugs Speech Therapy: After initial evaluation plus six (6) visits for office, and outpatient settings. s including Solid Organ and Bone Marrow (Cornea transplant does not require authorization) Transportation: non-emergent Air Transport. Unlisted & Miscellaneous Codes: Molina requires standard codes when requesting authorization. Should an unlisted or miscellaneous code be requested, medical necessity documentation and rationale must be submitted with the prior authorization request.

IMPORTANT INFORMATION FOR MOLINA HEALTHCARE MEDICARE PROVIDERS Information generally required to support authorization decision making includes: Current (up to 6 months), adequate patient history related to the requested services Relevant physical examination that addresses the problem Relevant lab or radiology results to support the request (including previous MRI, CT Lab or X-ray report/results) Relevant specialty consultation notes Any other information or data specific to the request The Urgent / Expedited service request designation should only be used if the treatment 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 will be handled as routine / nonurgent. If a request for services is denied, the requesting provider and the member will receive a letter explaining the reason for the denial and additional information regarding the grievance and appeals process. Denials also are communicated to the provider by telephone, fax or electronic notification. Verbal, fax, or electronic denials are given within one business day of making the denial decision or sooner if required by the member s condition. Providers and members can request a copy of the criteria used to review requests for medical services. Molina Healthcare has a full-time Medical Director available to discuss medical necessity decisions with the requesting physician. IMPORTANT MOLINA HEALTHCARE MEDICARE CONTACT INFORMATION Benefits & Benefits/ CALIFORNIA ( hours 8am-5pm local M-F, unless otherwise specified) 1 (800) 526-8196 1 (866) 472-6303 Pharmacy 1 (800) 665-0898 1 (866) 290-1309 1 (855) 322-4075 Provider Customer 1 (855) 322-4075 1 (562) 951-1529 1 (800) 665-0898 1 (310) 507-8196 1 (800) 665-0898 1 (866) 472-6303 Dental 1 (855) 214-6779 [TTY: 711] 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (866) 475-5423 1 (866) 913-4509 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (800) 327-4462 English: 1 (888) 275-8750 / TTY 711 Spanish: 1 (866) 648-3537 / TTY 711 FLORIDA ( hours 8am-5pm local M-F, unless otherwise specified) 1 (866) 472-4585 1 (866) 472-9509 Pharmacy 1 (888) 665-1238 1 (866) 290-1309 1 (855) 322-4076 Provider Customer 1 (855) 322-4076 1 (866) 948-3537 1 (866) 553-9494 1 (800) 221-5487 1 (800) 370-1116 Dental 1 (855) 214-6779 [TTY: 711]

IMPORTANT MOLINA HEALTHCARE MEDICARE CONTACT INFORMATION 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (800) 856-9994 (Secure Transportation) [TTY: 711] 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 English: 1 (888) 275-8750 / TTY: 711 Spanish: 1 (866) 648-3537 / TTY: 711 ILLINOIS ( hours 8am-5pm local M-F, unless otherwise specified) Prior 1 (855) 866-5462 1 (866) 617-4971 Pharmacy 1 (866) 901-8181 1 (866) 290-1309 Provider Customer 1 (855) 866-5462 Benefits/ 1 (877) 901-8181 1 (855) 866-5462 1 (866) 617-4971 Dental 1 (855) 866-5462 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (844) 644-6353 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (844) 456-2724 English: 1 (888) 275-8750 / TTY 711: 1 (866) 735-2929 Spanish: 1 (866) 648-3537 / TTY 711: 1 (866) 833-4703 Benefits/ MICHIGAN ( hours 8am-5pm local M-F, unless otherwise specified) 1 (888) 898-7969 1 (888) 295-7665 1 (855) 322-4077 Provider Customer 1 (855) 322-4077 1 (248) 925-1784 1 (800) 665-3072 1 (801) 858-0409 1 (888) 898-7969 1 (888) 295-7665 Dental 1 (800) 327-4462 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (855) 735-5604 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 1 (877) 627-2488 NEW MEXICO ( hours 8am-5pm local M-F, unless otherwise specified) 1 (877) 262-0187 1 (855) 278-0310 1 (855) 322-4078 Provider Customer 1 (855) 322-4078 1 (855) 278-0310 Benefits/ 1 (866) 440-0127 1 (801) 858-0409 1 (855) 315-5677 1 (888) 295-5494 Dental 1 (855) 214-6779 [TTY/TTD: 711]

IMPORTANT MOLINA HEALTHCARE MEDICARE CONTACT INFORMATION 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (888) 593-2053 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 TTY 1 (877) 627-2480 OHIO ( hours 8am-5pm local M-F, unless otherwise specified) Prior 1 (855) 322-4079 1 (877) 708-2116 Pharmacy 1 (855) 322-4079 1 (866) 290-1309 Provider Customer 1 (855) 322-4079 Benefits/ (8:00 a.m. to 8 p.m. 7/days week) 1 (866) 472-4584 1 (855) 322-4079 1 (866) 553-9262 Dental 1 (855) 322-4079 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (844) 491-4761 1 (866) 449-6843 (My Care Members only) 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (855) 322-4079 1 (888) 493-4070 SOUTH CAROLINA ( hours 8am-5pm local M-F, unless otherwise specified) Prior 1 (855) 237-6178 1 (866) 423-3889 Pharmacy 1 (855) 237-6178 1 (855) 571-3011 Benefits/ 1 (855) 882-3901 Provider Customer 1 (855) 237-6178 (8am-6pm) 1 (855) 237-6178 1 (866) 423-3889 Dental (DentaQuest) 1 (888) 307-6552 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (855) 882-3901 (LogistiCare) 1 (855) 237-6178 1 (866) 423-3889 Vision 1 (888) 493-4070 TEXAS ( hours 8am-5pm local M-F, unless otherwise specified) Prior 1 (855) 322-4080 Pharmacy 1 (866) 449-6849 1 (866) 290-1309 1 (866) 403-8293 Provider Customer 1 (855) 322-4080 1 (281) 599-8916 Benefits/ [TTY/TDD: 1 (866) 440-0012 or 711] 1 (866) 449-6849 1 (866) 617-4967 Dental 1 (855) 704-0430

IMPORTANT MOLINA HEALTHCARE MEDICARE CONTACT INFORMATION 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (844) 368-1500 (Secure Transportation) 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (800) 327-4462 Healthy Advantage Benefits/ Healthy Advantage UTAH ( hours 8am-5pm local M-F, unless otherwise specified) 1 (888) 483-0760 1 (855) 322-4081 1 (866) 472-9479 1 (888) 665-1328 [TTY TDD: 711] 1 (866) 472-9841 Provider Customer 1 (855) 322-4081 Dental 1 (855) 214-6779 1 (888) 483-0760 1 (866) 504-7262 1 (866) 472-9479 1 (866) 472-9481 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (844) 368-1501 (Secure Transportation) 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 1 (877) 627-2488 VIRGINIA ( hours 8am-5pm local M-F, unless otherwise specified) Prior 1 (844) 509-7583 Benefits/ 1 (844) 509-7583 1 (801) 858-0409 Provider Customer 1 (844) 542-7907 1 (801) 858-0409 1 (844) 509-7583 Dental 1 (855) 214-6779 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (844) 697-4337 (Secure Transportation) 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (855) 476-2724 Benefits/ WASHINGTON ( hours 8am-5pm local M-F, unless otherwise specified) Pharmacy 1 (800) 869-7185 1 (800) 869-7791 1 (800) 869-7185 1 (855) 322-4082 1 (800) 665-1029 1 (800) 869-7165 1 (800) 816-3778 Provider Customer 1 (800) 665-1029 1 (855) 322-4082

IMPORTANT MOLINA HEALTHCARE MEDICARE CONTACT INFORMATION 1 (800) 869-7185 1 (800) 767-7188 Dental N/A N/A 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (800) 869-7185 1 (800) 767-7188 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 1 (866) 772-0285 IP Auths OP Auths Benefits/ WISCONSIN ( hours 8am-5pm local M-F, unless otherwise specified) 1 (888) 999-2404 1 (877) 708-2117 Pharmacy 1 (888) 665-1328 1 (888) 373-3059 1 (855) 326-5059 1 (855) 315-5663 1 (801) 858-0465 Provider Customer 1 (855) 326-5059 1 (801) 858-0465 1 (888) 999-2404 1 (877) 708-2117 Dental 1 (855) 214-6779 1 (855) 714-2415 1 (877) 731-7218 Transportation 1 (866) 475-5423 (LogistiCare) 1 (855) 714-2415 1 (877) 813-1206 Vision 1 (888) 493-4070 Providers may utilize Molina Healthcare s Website at: https://provider.molinahealthcare.com/provider/login Available features include: Authorization submission and status Claims submission and status Member Provider Directory Frequently used forms Nurse Advice Line Report

Molina Healthcare Medicare Prior Authorization Request Form [Please refer to Contact/FAX numbers above] Plan: Molina Medicare MEMBER INFORMATION Member Name: DOB: / / Member ID#: Phone: ( ) - Type: Elective/Routine Expedited/Urgent 1 1 Definition of Expedited/Urgent 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. Inpatient Surgical procedures Admissions SNF LTAC REFERRAL/SERVICE TYPE REQUESTED Outpatient Surgical Procedure OT PT ST Diagnostic Procedure Hyperbaric Therapy Infusion Therapy Pain Management Other: Home Health DME Wheelchair In Office Diagnosis Code & Description: CPT/HCPC Code & Description: Number of visits requested: DOS From: / / to / / Please send clinical notes and any supporting documentation Requesting Provider Name: Servicing Provider or Facility: Contact at Requesting Provider s office: PROVIDER INFORMATION NPI#: NPI#: TIN#: TIN#: Phone Number: ( ) - Fax Number: ( ) - For Molina Use Only: Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member s eligibility on the date of service, benefit limitations/exclusions and other applicable standards during the claim review, including the terms of any applicable provider agreement.

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