Washington Marketplace - Utilization Management

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:

1. Applicable federal or state mandates and guidelines as required
2. American Society of Addiction Medicine (ASAM)
3. Molina WA Merge Criteria - Molina Medicaid prior authorization (PA) criteria which includes Health Care Authority (HCA) guidance on certain procedures
4. Molina WA Pharmacy Criteria - Policies and guidelines intended to be a resource for relevant information about drugs, treatment and coverage
5. Molina Clinical Policy (MCP) - Corporate guidance documents addressing new or existing technology
6. 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 - 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) and PA information.
• Information regarding Sepsis Guidelines.
• 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 Utilization 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 Process

For Medicaid or Marketplace members:

In order to avoid the appeal process, providers can request a Peer-to-Peer discussion with a Molina Medical Director. The requesting provider has 10 business days for inpatient, or within 5 business days of discharge, and 10 business days of pre-service from receipt of the adverse benefit determination (denial) notification (verbal or fax notification), or any time before a decision is made, to schedule a Peer-to-Peer.

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
• Please use the reconsideration process first for denials when no clinical information was provided. This may result in an approval or a revised denial that would come with new Peer-to-Peer and reconsideration timeframes
• May not be requested if a formal appeal has been filed
• Time period to request a Peer-to-Peer: 3 business days

Reconsideration by the Utilization Management Department

• 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 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 unable to request a Peer-to-Peer within 3 business days after the adverse benefit determination (denial) notification
• Reconsideration cannot be requested after a Peer-to-Peer discussion. Please follow appeal pathway for further dispute rights
• Time periods 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.

Molina Medical Directors will be available to schedule a Peer-to-Peer Monday through Friday from 9 a.m. to 4 p.m. PST, excluding holidays. For Advance Imaging (AI) authorizations, please call (855) 714-2415 (option 1). A Molina Medical Director will call you at your scheduled date and time, at the direct number provided.

• 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)