Passport by molina pharmacy prior authorization form Box 36030 Louisville, KY 40233 Authorization for outpatient therapy is not required until the 21st visit. Member DOB . • Passport has a full-time Medical Director available to discuss medical necessity decisions with the requesting physician at (800) 578-0775. T. Dental: Molina Healthcare, Inc. Q2 2024 Marketplace PA Guide/Request Form (Vendors) Effective 04. *Indicates Required Field. Please contact MedImpact for Diabetic Supply questions: Please enter all the mandatory fields for Molina Healthcare, Inc. Go online to www. The 270/271 and 276/277 transactions are handled by Passport’s contracted clearinghouse The SSI Group. 1 . You are leaving the Molina Healthcare website Passport Health Plan by Molina Healthcare . In some cases, they will be made available through Molina Healthcare’s vendor, Prior Authorization is not a guarantee of payment for services. The example above shows the branded, generic, and trademarked generic forms of the drug “warfarin sodium”. Are you sure? ok cancel. Last Name: Member’s . Member Name: DOB: Date: Member ID #: Sex: Weight: Height: Provider Information Prescriber Name and Specialty: NPI #: Office Contact Name: Prescriber Address: Office Phone: Office Fax: Molina Healthcare, Inc. Prior Authorization Call Center: (844) 336-2676. indd 1 07/06/23 9:30 PM. o Authorization for outpatient therapy is not required until the 21st visit. Your provider has been instructed to contact MedImpact for additional information on how to submit a prior authorization. Molina Healthcare Medical Insurance Marketplace; Many self-administered and office-administered injectable products require Prior Authorization (PA). Cosmetic, Plastic & Reconstructive Authorization except for Podiatry Surgical Procedures Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures These codes are exempt and DO NOT website or by contacting Passport. Check the box of the MCO in which the member is enrolled Anthem BCBS Medicaid Aetna Better Health Humana Passport Health Plan WellCare of Kentucky Not all plans requirePAs for the same services. on directly to your office or the member’s home. FFECTIVE: 01/01/2024. Physician administered drugs (PAD) are covered through Passport. Q1 2024 Marketplace PA Guide/Request Form (Vendors) Effective 01. Members are allowed 20 visits per therapy per calendar year without an authorization . CM Fax: (800) 983-9160 . gov\) Pharmacy Prior Authorization Forms Health Resources. Fourth Quarter 2022. 8 Requirements for prior authorization submission . Member Information Member Name: DOB: Date: Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA, Title: Molina Healthcare, Inc. Q1 2022 Marketplace PA Guide/Request Form (Vendors) Effective 01. AROUND TIMES Here you can find forms for Molina Healthcare of Virginia providers in one place. Physician Administered Drugs (Passport): Prior Authorization Pre-Service Review Guide & Request Form (Please use this form to request a PA for medically billed drugs including J Codes) Passport by Molina Healthcare, Inc. Our Member Services team can help you. Need a Prior Authorization? Code LookUp Tool . olina Healthcare . Please use one form per member. com There are three ways to enroll in the Passport Medicaid plan: Call Passport at (833) 576-1813, TTY 711. Dental: 33053FRMMDWAEN_Revisions to 2118 2025 Prior Authorization Guide and Request Form. FMT Agents Prior Authorization Form Addendum Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 KY Medicaid Universal PA Request Form – Pharmacy Benefit. 01. BH Prior Authorization Request Passport by Molina Healthcare. Continuous Glucose Monitoring SA Form; Antimigraine Agents, Others SA Form -- updated June 2024;. Check with the plan before submitting Please contact MedImpact for Pharmacy Claims questions: Technical Call Center: (800) 210-7628. 2022 REFER TO MOLINA’S PROVIDER WEBSITE OR PRIOR AUTHORIZATION Many self-administered and office-administered injectable products require Prior Authorization (PA). December 31, 2022. Fax: 1 (844) 312-6371. – Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508, Created Date: 5/6/2024 10:51:21 AM Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 Fill Molina Prior Authorization Form, Edit online. 2024 Medicaid PA Guide/Request Molina® Healthcare, Inc. Providers can access the most current Provider Molina® Healthcare, Inc. 11 Encourage your patients to use My Health Perks! 12 Our gift to our providers: PsychHub subscription! Passport Health Plan by Molina Healthcare Marketplace versiones anteriores del mismo ya no se prescription and pharmacy information into the Drug Look-Up tool. Fax: (800) 869-7791. – Pharmacy Prior Authorization Request Form Providers may utilize Molina’s Provider Portal: Molina Healthcare, Inc. Molina Medicare/ MyCare Ohi. Page 1 of 5 Passport by Molina® Healthcare of Kentucky Marketplace Prior Authorization/ Pre-Service Review Guide Effective: 10/01/2023 Refer to Molina’s Provider website or prior authorization look-up tool/matrix for Instructional Information for Prior Authorization. Prior Authorization Fax Line: (858) 357-2612. a convenient Provider change form can be found on the Passport website at Do whatever you want with a Kentucky Marketplace Pharmacy Prior Authorization Request Form. – Pharmacy Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508 Created Date: 5/6/2024 10:57:37 AM A Molina Healthcare prior authorization form is submitted by a physician to request coverage for a patient's prescription. Physician Administered Drugs (Passport): Prior Authorization Pre-Service Review Guide & Kentucky Medicaid MCO Prior Authorization Request Form . Member ID # Sex . Fax: (800) 869-4325 . Attach any additional documentation that is important for the review, e. alertline. 2021 Refer to Molina’s Provider Website/Prior Authorization Look-Up Tool/Matrix for Specific Codes that Require Authorization O NLY C OVERED S ERVICES A RE E LIGIBLE F OR R EIMBURSEMENT O FFICE V ISITS T O C ONTRACTED /P ARTICIPATING P RIMARY C ARE P ROVIDERS D O Many self-administered and office-administered injectable products require Prior Authorization (PA). Title: Molina Healthcare, Inc. Drug PA Fax: (858) 357-2612. Drug PA Fax: (858) 357-2612 . Providers may utilize Passport’s Website at: Prior Authorization is not a guarantee of payment for services. Height/Weight . , CA): Member Name: DOB (MM/DD/YYYY): Download Kentucky Marketplace Pharmacy Prior Authorization Request Form. Fax . 2024 • Fax: (Fax: (Pho Fax: (Information genera Retail pharmacy drugs should be billed to MedImpact. Pharmacy related inquires can be directed to MedImpact at the number below: Phone : (800) 210-7628 . Molina Healthcare of Illinois Medical Prior Authorization Request Form For Medicaid and MMP/Dual Options Plans. It is valid for the duration indicated on the Medication Request Authorization (MRA). Drug PA Fax : (858) 357-2612 . Member’s . , CA): Member Name: DOB (MM/DD/YYYY): Refer to Molina’s Provider Website or Prior Authorization Look-Up Tool for specific codes that require Pharmacy Authorizations: Phone: (800) 977-2273 Fax: (800) 869-4325 . Pharmacy Paper Claims Fax: (858) 549-1569 . Aetna Better Health of Kentucky . 278 Referral Certification and Authorization Form The formulary is a list of covered drugs. Provider change form can be found on the Passport website at Passport by Molina Healthcare Q1 2024 Marketplace PA Guide/Request Form (Vendors) Pharmacy Authorizations: Member Customer Service, Benefits/Eligibility: Phone: (855) 322-4077 Healthcare – BH Prior Authorization Request Form. Service Authorization Forms . You are leaving the Passport by Molina Healthcare website. NCH TURN . Please submit claims to Passport Health Plan by Molina Healthcare KY using the NCH prior authorizatio n number. prescripti. 31369FRMMDOHEN_OH_2023_Medicaid_Prior_Authorization_Form. For retail pharmacy drug prior authorization requests Providers should fax their requests to the fax number below. – Pharmacy Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508, Created Date: 5/6/2024 10:57:37 AM Passport Health Plan by Molina Health care Kentucky Marketplace Pharmacy Prior A uthorization Request Form For Drug PA Requests, Fax: (844) 802-1406. DOB . When providing required clinical information, the following elements should be considered within the rationale to support your medical necessity request: o. Passport Health Plan by Molina Healthcare Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA Requests Author: Molina Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA, Passport Health Plan by Molina Healthcare, Duration Outcome & Reason for Discontinuation Created Date: 1/21/2022 2:54 Here you can find all of the Passport Health Plan Medicare provider forms in one Psychological and Neuropsychological Assessment Supplemental Form. If Molina extends the time, we must be able to tell SCDHHS how the delay is best for you. MAP 9 –MCO 2020 Medical Precertification 1-855-661-2028 1-800-964-3627 www. Page 1 of 5 Passport by Molina® Healthcare of Kentucky Marketplace Prior Authorization/ Pre-Service Review Guide Effective: 10/01/2023 Refer to Molina’s Provider website or prior authorization look-up tool/matrix for Passport by Molina Healthcare Q1 2024 Marketplace PA Guide/Request Form (Vendors) Pharmacy Authorizations: Member Customer Service, Benefits/Eligibility: Phone: (855) 322-4077 Healthcare – BH Prior Authorization Request Form. availity. For Molina Use Only: Prior Authorization is not a guarantee of payment for services. Title: Molina Healthcare of Mississippi Medicaid Prior Authorization Author: Prior Authorization Request Pharmacy Authorization Please provide the information below. REFER TO PASSPORT’S PROVIDER WEBSITE OR PRIOR AUTHORIZATION LOOK -UP. Prior authorization for services not currently listed as a Medicaid benefit may be considered for coverage under the case-by-case exception or DME Exceptional Circumstance Provision when prior authorized and Passport Health Plan by Molina Healthcare Prior Authorization Request Form . Tax ID For Passport Members About Molina. Healthcare WellCare of Kentucky Pharmacy PAs & Appeals 1 - 844-795-3508, 1-844-802-1406 : P; harmacy : Prior Authorization Request Form Keywords: Kentucky Medicaid MCO, MCO Prior Authorization Phone Numbers, Molina Healthcare Created Date: MAP 9 –MCO 052018 . Pharmacy related inquires can be directed to MedImpact at the number below: Phone: (800) 210-7628; Prior Authorization Call Center: (844) 336-2676; Drug PA Fax: (858) 357-2612 Prior Authorization Form Private Duty/Attendant Nursing Care (March 2024 Member Grievance Form . Prior Authorization Call Center: (844) 336-2676. EDI Forms. We require advanced approval of coverage on some drugs before they will be paid for. Passport by Molina Healthcare Outpatient therapy request form Member Name. to offer . Prior Authorizations: (844 Prior Authorization is not a guarantee of payment for services. indd 1 8/4/23 9:50 AM. Phone . If you are not currently a Molina Healthcare provider, but are interested in contracting with us, please call Passport Provider Services at (800) 578-0775. Requests . *New York Providers will continue to submit transactions through Claimsnet. Brokers. Electronic Please see the Clinical PA criteria that Molina has implemented below. Molina requires standard codes when requesting authorization. Download Prior Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 Passport Health Plan by Molina Healthcare Important Marketplace Contact Information PROVIDERS: Pharmacy: • Provider Services PH: 644-1621 • Prior Authorization Fax: (833) 322-1061 COMPLIANCE: Report Fraud, Waste & Abuse: Compliance AlertLine PH: (866) 606-3889 https://Molinahealthcare. com Dental (DentaQuest) 1-800-508-6787 1-262-834-3589 You can ask Molina to extend the time to resolve your appeal by up to 14 calendar days. Check the box of the MCO in which the member is enrolled . The transactions may be sent directly to SSI or via your own clearinghouse. Passport Health Plan by Molina. Fax: (866) 290-1309. The training is Behavioral_Health_Prior_Authorization_Form-cwl_31171OTHMDKYEN. Securely download your document with other editable Title: Kentucky Medicaid Pharmacy Prior Authorization Form Author: Medimpact Subject: Kentucky Medicaid Pharmacy Prior Authorization Form Keywords website or by contacting Passport. indd 3 23/12/24 8:17 PM. You cannot request one. Q2 2022 Medicare PA Guide/Request Form Pharmacy Authorizations: Phone: (800) 665-3086. PA; Prior Authorization is required. MEMBER INFORMATION . Some treatments and services must be approved by your doctor or Passport. Q4 2023 Marketplace PA Guide/Request Form (Vendors) Effective 10. Prior Authorizations: (844) 336-2676. 2 Drug coverage change . with Prior Authorization, quantity limit ; FESOTERODINE TAB 8MG ER : Generic added to formulary, Title: Molina Healthcare, Inc. 2025 Medicaid PA Guide/Request Form Effective 01. Pharmacy Forms. “Passport” has the same meaning as “Health Plan” in For Behavioral Health crisis assistance call the Passport Behavioral Health Crisis Hotline, available 24 hours per day, seven days per week at (844) 800-5154. Get Automatic Approval for Advanced Imaging Prior Authorization . 18 53593MS190903 . Title: Prior Authorization Request Form Author: Molina Healthcare Subject: Prior Authorization Request Form Keywords: Prior Authorization Request Form Molina Healthcare, Inc. Last Updated: January 2022. – Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508, Created Date: 5/6/2024 10:51:21 AM list will tell you if the branded form, the generic form, or the trademarked generic form is what is covered. We’ll help you enroll. Member Customer Service, Benefits/Eligibility. 26235FMLMPKYEN 210806. O. com Pharmacy 1-855-661-2028 Retail Drug: 1 -855-875-3627 Medical Injectable: 1 Pharmacy Prior Authorization Forms Health Resources. MCG Health. https: Passport Health Plan by Molina Healthcare. • For ALL Opioid Requests — Complete page 1, 2,3 AND page 4 of this form. UIDE . 2024 . Passport Advantage (HMO) 2024 Rx Mail Order Form 2024 Coverage Determination Request Form 2024 Redetermination Form. MississippiCAN Prior Authorization Request Form Effective 10. Inside Passport Advocates; Marketplace Brokers; Member Materials and Forms Pharmacy and Prescription Drugs; Kentucky DSNP Member Advisory Committee; Refer to Molina’s Provider website or Prior Authorization Look-up Tool/Matrix for specific codes that require authorization. com Kentucky Medicaid Pharmacy Prior Authorization Form • For Drug Requests (unless noted below) — Complete ONLY page 1 of thisform. Tell Us what You Think. 2025 Molina® Healthcare, Inc. Molina Healthcare, Inc. Please print your answer, attach supporting documentation, sign, date, and return to our office as soon as possible to expedite this request. Inside Passport Advocates; Marketplace Brokers; Find a Doctor or Pharmacy; About Molina Healthcare, Inc. This form completed by Phone # MCO Prior Authorization Phone Numbers ANTHEM BLUE CROSS BLUE SHIELD KENTUCKY DEPARTMENT PHONE FAX/OTHER Physician Administered Drug Prior Authorization 1-855-661-2028 1-800-964-3627 1-844-487-9289 To submit electronic prior authorization (ePA) requests online, www. Molina’s pharmacy vendor will coordinate with MH and ship the . Molina can also extend the time to resolve your appeal by up to 14 calendar days if Molina thinks that the delay is best for you. be submitted with the prior authorization request. Prior Authorizations: (844 REFER TO PASSPORT'S WEBSITE OR PRIOR AUTHORIZATION LOOK-UP TOOL / MATRIX FOR SPECIFIC CODES THAT REQUIRE Medical Pharmacy Authorization (800) 578-0775 (844) 802-1406: Molina Healthcare Subject: Authorization Review Guide 2023 Keywords: Authorization Review Guide 2023, Passport partners with MedImpact for prescription drugs. OOL /M. Passport by Molina Healthcare Provider frequently used forms for claims, prior authorization and more. – Prior Authorization Request Form. DATE OF REQUEST: MEMBER INFORMATION FOR PASSPORT BY MOLINA HEALTHCARE PROVIDERS In this issue 1 Claims submission . UnitedHealthcare Community Plan. g. Passport has partnered with . Confidentiality: The information contained in the Passport Health Plan by Molina Healthcare Prior Authorization Service Request Form Important Information For Passport Marketplace Providers Information generally required to support authorization decision making includes: • Current (up to 6 months), adequate patient history related to the requested services. o. Passport prior authorization documents are updated annually, or more frequently as appropriate. Clinical Policies You are leaving the Passport by Molina Healthcare website. For information regarding Passport by Molina Healthcare Medicaid and Medicare Programs, visit PassportHealthPlan. This form completed by Phone # MCO Prior Authorization Phone Numbers ANTHEM DEPARTMENT PHONE FAX/OTHER Physician Administered Drug Prior Authorization 1-855-661-2028 1-800-964-3627 1-844-487-9289 To submit electronic prior authorization (ePA) requests online, www. To qualify, member must have Passport by Molina Healthcare Medicaid. Phone: (833) 685-2103. Physician administered drugs are covered through Passport. Your PCP will take care of any authorizations you need. Pharmacy PAs & Appeals (844) 795-3508, (844) 802-1406: Physician Administered Drug PAs Kentucky Medicaid MCO Prior Authorization Request Form, Molina Healthcare, MOLINA HEALTHCARE Prior Authorization (PA) Form PRESCRIPTION DRUG AZ-PF-20145-21 If the following information is not complete, correct, or legible, the PA process can be delayed. Over‐the‐Counter dosage forms are covered on the drug list with a valid prescription from a provider. Passport by Molina Healthcare. What drugs does Passport Health Plan cover? Refer to Molina’s Provider website or Prior Authorization Look-Up Tool for specific codes that require Prior Authorization Pharmacy Authorizations: Phone: (855) 322-4082 . Prior Authorization Request Form . Pharmacy PAs & Appeals 1-844-795-3508, 1-844-802-1406: Kentucky Medicaid MCO Prior Authorization Request Form, Molina healthcare, Anthem Blue Cross Blue Shield, WellCare of Kentucky Created Date: Please contact MedImpact for Pharmacy Claims questions: Technical Call Center: (800) 210-7628. 12 of the Kentucky Managed Care Contract. o Opt-In Outpatient/D-SNP/DME (excluding Home Health) Authorization is required prior to the 36th UDT. For additional information on submitting prior authorizations, please see the provider forms section on the KY MedImpact Provider Passport Health Plan by Molina Healthcare Prior Authorization Service Request Form Important Information For Passport Marketplace Providers Information generally required to support authorization decision making includes: • Current (up to 6 months), adequate patient history related to the requested services. You are leaving the Molina Healthcare website. Page 1 of 5 Passport by Molina® Healthcare of Kentucky Marketplace Prior Authorization/ Pre-Service Review Guide Effective: 10/01/2023 Refer to Molina’s Provider website or prior authorization look-up tool/matrix for Some exclusions apply. Payment Policies Please note that the effective date of any payment policy, and any subsequent revision to a payment policy, shall not be less than 30 days following the date of publication of that revision, pursuant to Section 27. Benefits subject to change. What is a prior authorization? A. 2022 . com Passport Health Plan by Molina Healthcare (Passport Health Plan or Passport) Marketplace Product . Prior Authorization Specialty Medication Request Form. Fax: (888) 373-3059 . Deﬁnitive UDT Codes: G0480, G0482, G0483, G0659; The ﬁrst 16 UDT do not require authorization and do not have a PA limit. Pharmacy. Should an unlisted or miscellaneous code be requested, medical necessity documentation and rationale must be submitted with the prior authorization request. e. Tax ID . By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. WellCare of Kentucky. G. Passport Health Plan by Molina Healthcare Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA Requests, Fax: (844) 802-1406. When an approval is needed, it is called a “prior authorization”. Medicine allergies . For Injectables only: Facility name Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA Requests, Fax: (844) 802-1406. Obtaining authorization does not guarantee payment. You need a prior authorization to make sure that the care and services you receive are medically necessary. The plan retains the right to review benefit Services must be a covered health plan benefit and medically necessary with prior authorization as per plan policy and procedures. 1. Date . Member Services: (800) 578-0603 Nurse Advice Line: (800) 606-9880 Behavioral Health Crisis Line: (844) 800-5154 IMPORTANT INFORMATION FOR MOLINA MEDICARE PROVIDERS Information generally required to support authorization decision making includes: • Current (up to 6 months), adequate patient history related to the requested services. Member Name: DOB: Date: Member ID #: Sex: Weight: Height: Provider Information Prescriber Name and Specialty: NPI #: Office Contact Name: Prescriber Address: Office Phone: Office Fax: PASSPORT HEALTH PLAN BY MOLINA HEALTHCARE Passport Health Plan by Molina Healthcare (Passport Health Plan or Passport) Medicaid 2022 . Authorization for outpatient therapy is not required until the 21st visit. Phone Q4 2023 Marketplace PA Guide/Request Form (Vendors) Effective 10. Cookies are used to improve the use of our website and analytic purposes. Member Name: DOB: Date: Member ID #: Sex: Weight: Height: Passport Health Plan by Molina Healthcare Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug P A Requests, Pharmacy Prior Authorization Forms . For questions or comments about your coverage, or for more information, Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 Passport Health Plan by Molina Healthcare Prior Authorization Service Request Form Important Information For Passport Marketplace Providers Information generally required to support authorization decision making includes: • Current (up to 6 months), adequate patient history related to the requested services. Phone: (800) 210-7628. ID Number: Date of Birth: – – Member Molina Healthcare, Inc. Upon our review of all required information, you will be contacted by the health plan. Passport Health Plan by Molina Healthcare DME Request Form MUST BE COMPLETED. Members are allowed 20 visits per therapype r calendar year without an authorization. If reward is offered for both Molina Medicaid and Medicare, it can only be claimed once Title: Molina Healthcare, Inc. kynect. INCOMPLETE FORMS WILL BE REJECTED. ky. Member Materials and Forms Pharmacy and Prescription Drugs; Kentucky DSNP Member Advisory Committee; Helpful The authorization for the benefits has ended or the limits are Mail a letter, call or fax the request to: Passport by Molina Healthcare Attention: Appeals & Grievances Department P. The forms are also available on the Frequently Used Forms page. Payment is made in accordance with a determination of the member’s eligibility, benefit limitation/exclusions, evidence of Molina Healthcare, Inc. This is done to make sure that you get the right care. ky. Member Name . • Neuropsychological and Psychological Testing • Non-Par Providers/Facilities: some Molina Healthcare of Mississippi Provider frequently used forms for claims, prior authorization and more. Emergency services do not require prior authorization. Title: Passport by Molina Healthcare Behavioral Health service Passport by Molina Healthcare Behavioral Health service request form Keywords: Passport by Molina Healthcare Behavioral Health service request form, Molina Healthcare Created Date: 6/7/2023 Molina® Healthcare, Inc. MyCare Ohio Opt-Out Fax: (866) 449-6843. PLEASE NOTIFY MOLINA UPON The NCH authorization will start with an “AR” followed by at least 4 digits (e. IMPORTANT INFORMATION FOR MOLINA HEALTHCARE MEDICAID PROVIDERS. Radiation, Sleep, Molecular Tests : Medicaid Fax: (877)731-7218 MMP Fax: (844)251-1451 ***PA NOT REQUIRED FOR PLANNED ADMISSIONS. Items on this list will only be dispensed after prior authorization from Molina Healthcare. 2024 • Fax: (Fax: (Pho Fax: (Information genera Medicare Prior Authorization Review Guide Medicare Prior Authorization Form Pharmacy Prior Authorization Participating Providers are encouraged to interact with Passport’s Medicaid/CHIP Prior Authorization Annual Review Change Log Medicaid/CHIP Prior Authorization Annual Review Report Prior Authorization Assistance - Molina Im website or by contacting Passport. 9 Council for Affordable Quality Healthcare . Passport Health Plan by Molina Healthcare (Passport Health Plan or Passport) Marketplace Product . Requesting Provider. Try Now! Passport Health Plan by Molina Healthcare Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA Requests Author: Molina Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA, Passport Health Plan by Molina Healthcare, Duration Outcome & Reason for Discontinuation Created Date: 1/21/2022 2:54 Behavioral Health Service Request Form Author: Molina Healthcare Subject: Behavioral Health Service Request Form Keywords: Passport Health Plan, Behavioral Health Service Request Form Created Date: 10/12/2020 10:06:23 AM Welcome to Passport by Molina Healthcare! We are glad you made the decision to become a part of our network. 2021 Medicare PA Guide/Request Form Effective 01. If Prior Authorization is required for a drug or Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 Passport Health Plan by Molina Healthcare Prior Authorization Service Request Form Important Information For Passport Marketplace Providers Information generally required to support authorization decision making includes: • Current (up to 6 months), adequate patient history related to the requested services. Pharmacy Prior Authorization Forms Health Resources. com Remit Claims to: Passport Health Plan by Molina Healthcare, website or by contacting Passport. *DATE OF REQUEST: / / *PRIORITY: Standard (Non-Urgent) Urgent Passport Health Plan by Molina Healthcare Kentucky Marketplace Pharmacy Prior Authorization Request Form For Drug PA Requests, Fax: (844) 802-1406. Member ID . – BH Prior Authorization Request Form MEMBER INFORMATION Line of Bus iness: ☐Med caid Ma rketplac e Date of Request: State/Health Plan (i. Out-patient (OP) Prior Authorizations (Includes Behavioral Health Authorizations): PHARMACY DRUG/PRODUCT PRIOR AUTHORIZATION FORM Instructions: Fill out all applicable sections completely and legibly. Member information Member Name . Q1 2025 Matrix. Obtain additional guidance on how to submit a 72-hour emergency override here. To ensure the most current information is being utilized, providers are encouraged to access the guide posted in the Frequently Used Forms section. FAX responses to: (844) 259-1689. Passport byMo lina Healthcare Outpatient Therapy Request Form . 2023 Molina Healthcare, Inc. Clinical Policies Prior Authorization Fax: (844) 336-2676 (8am - 7pm EST, 7 days per week) March Vision You may do so by contacting the Passport by Molina Healthcare AlertLine or by submitting an electronic complaint using the website listed below. The Provider Manual is customarily updated annually but may be updated more frequently as policies or regulatory requirements change. CA): Member providers and referrals to network specialists do not require prior authorization. Pharmacy PAs & Appeals (844) 795-3508, (844) 802-1406: Physician Administered Drug PAs Kentucky Medicaid MCO Prior Authorization Request Form, Molina Healthcare, This form completed by Phone # MCO Prior Authorization Phone Numbers ANTHEM BLUE CROSS BLUE SHIELD KENTUCKY DEPARTMENT PHONE FAX/OTHER Physician Administered Drug Prior Authorization 1-855-661-2028 1-800-964-3627 1-844-487-9289 To submit electronic prior authorization (ePA) requests online, www. ATRIX FOR SPECIFIC CODES THAT REQUIRE AUTHORIZATION. com MHO-0709 Effective 1/1/2020 21231 OH Medicaid Service Request Form. Passport Health Plan by Molina Healthcare Outpatient Therapy Request Form . , chart notes or lab data, to support the request. When the branded form of a drug is covered, the drug name will be listed in all CAPITAL letters as its BRAND NAME. – Prior A uthorization Request Form. • For Hepatitis C Direct Acting Antiviral (DAA) Therapy — Complete page 1 AND page 5 of this form. 2024 • Fax: (Fax: (Pho Fax: (Information genera Only your provider can request a prior authorization to Molina Healthcare. 2025 Marketplace PA Guide/Request Form (Vendors) Effective 01. Molina ® You can go to any OB/GYN doctor in the Passport by Molina Healthcare network as well as receive Certified Nurse Midwife (CNM) services without a prior authorization. indd 1 12/30/19 1:30 PM Molina Healthcare. Select your plan year to find a pharmacy. For information regarding Kentucky Medicaid Single PDL Prior Authorization Criteria please click here. self-service for advanced imaging and return the Attestation Form to Passport no later than . Member ID. Molina Medicaid/ M MolinaHealthcare. , CA): Member Name: DOB (MM/DD/YYYY): Prior Auth LookUp Tool; Prior Auth Pre-Service Review Guide Request Form; Universal Prior Auth Request Form; Advocates & Brokers. Payment is made in accordance with a determination of the member’s eligibility on the date of service, benefit For Molina Use Only: Molina® Healthcare, Inc. WellCare of Kentucky . Passport Health Plan will generally cover any prescription drug listed in our formulary if: the drug is medically necessary, the prescription is filled at a Passport Health Plan network pharmacy, and other plan rules are followed. gov or call Kynect at (855) 459-6328, TTY 711; Call the Department for Community Based Services (DCBS): (855) 306-8959 Q. Kentucky Health Information Exchange (KHIE) Passport is dedicated to improving the health and quality of life of our members and actively supports the statewide implementation of the Kentucky Health Information Exchange Home| Passport by Molina Healthcare. Here are some services you may need that require a prior authorization: Home health care Passport by Molina Healthcare Q1 2024 Marketplace PA Guide/Request Form (Vendors) EVIEW . Availity. ©2024 Passport by Molina Healthcare, Inc. Capitalized words or phrases used in this Provider Manual shall have the meaning set forth in your Agreement with Passport by Molina Healthcare, Inc. Sign, fax and printable from PC, iPad, tablet or mobile with pdfFiller Instantly. Pharmacy . By "checking this box" or "providing your signature", you are acknowledging and affirming agreement to provide services as authorized per this waiver service plan. Effective 1/1/2020. Authorization is required prior to the 17th UDT. M. – BH Prior Authorization Request Form Providers may utilize Molina’s Provider Portal: • Claims Submission and Status • Authorization Submission and Status • Member Eligibility MEMBER INFORMATION Line of Business: ☐ Duals Date of Request: ☐ Medicare ☐ CA EAE (Medicaid) State/Health Plan (i. For any questions on your pharmacy coverage prior to July 1, 2021, please contact Member Services at (800) 578 This form completed by Phone # MCO Prior Authorization Phone Numbers ANTHEM BLUE CROSS BLUE SHIELD KENTUCKY DEPARTMENT PHONE FAX/OTHER Physician Administered Drug Prior Authorization 1-855-661-2028 1-800-964-3627 1-844-487-9289 To submit electronic prior authorization (ePA) requests online, www. 2024 • Fax: (Fax: (Pho Fax: (Information genera Learn more about your health plan, what’s covered and the many programs we offer you and your family. CPT Codes Requiring Prior Authorization Page 1 of 16 Behavioral Health Mental Health, Alcohol & Chemical Dependency Services Chiropractic Services. First Name: M. It should be noted that the medical office will need to provide justification for requesting the specific Provider Website or Prior Authorization Look-Up Tool for specific codes that require Pharmacy Authorizations: Phone: (800) 977-2273 . Please enter all the mandatory fields Your agreement to provide this service is required. com. Passport Health Plan by Molina Healthcare: fill, sign, print and send online instantly. , AR1000). Ordering Provider Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 Pharmacy Program Phone Numbers: Member and Provider Assistance (24/7): (800) 210-7628 Clinical / Prior Authorizations Only: (844) 336-2676 Providers: For prior authorization, eligibility, claims or benefits call (800) 578-0775 or visit Provider Portal at www. Rendering Provider Name. The Universal Prior Auth Request Form; Advocates & Brokers. We use cookies on our website. Referral Forms Molina In-Network Referral Form (Updated March 2022) Disease Management Form (March 2022) Provider Contract Request (non-par Find a Doctor or Pharmacy. Prior Authorization Request Form Phone: 1-877-872-4716 Expedited/Urgent Fax number for Pharmacy J-code requests: 1-844-823-5479 Fax number for Medical and Inpatient requests: 1-866-879-4742. Are you sure? Please enter all the mandatory fields for the form to be submitted Please select captcha. Who can I call with questions, concerns or complaints? A. While supplies last. For retail pharmacy drug prior authorization requests, please fax your requests to the fax number below. MEMBER INFORMATION. Passport by Molina Healthcare Q1 2024 Marketplace PA Guide/Request Form (Vendors) Pharmacy Authorizations: Member Customer Service, Benefits/Eligibility: Phone: (855) 322-4077 Healthcare – BH Prior Authorization Request Form. Cite AutoAuth. Ordering Provider Name . Medicaid Professionals. This link will take you away from the Dual Options section of MolinaHealthcare. (Passport) Medicaid 2024 . Pharmacy phone . In some cases, they will be made available through Molina Healthcare’s vendor, aremark Specialty Pharmacy. Prior Authorization Fax: (833) 322-1061 . Anthem Blue Cross Blue Shield. You can go to any qualified provider of your choice for family planning services. Physician Administered Drugs (Passport): Prior Authorization Pre-Service Review Guide & Request Form (Please use this form to request a PA for medically billed drugs including J Codes) Pharmacy Prior Authorization Request Form To process this request, please fill out all boxes and attach notes to support the request. Pharmacy Authorizations: : Phone: (855) 322-4077 . com KY Medicaid Universal PA Request Form – Pharmacy Benefit. Please contact MedImpact for Diabetic Supply questions: Technical Call Center: (800) 210-7628. Compound ingredients . Payment is made in accordance with a determination of the membe r’s eligibility, benefit limitation/exclusions, evidence of medical necessity and other applicable standards during the claim revie w. Molina Molina Healthcare – Prior Authorization Request Form, Molina Healthcare Created Date: 10/20/2023 3:15:09 PM When these exceptional needs arise, the physician may fax a completed Prior Authorization Form to Molina Healthcare at 1-844-823-5479. gov \(https://www. Q. Phone: (844) 782-2678 option 2 Fax: (877) 281-5364 . O. This manual will provide you with information about Passport and will describe how we will work together as you care for your patients’ health care needs. – Prior Authorization Request Form Author: CQF Subject: Accessible PDF Keywords: 508, Created Date: 5/6/2024 10:51:21 AM Prescription Prior Authorization Forms Pharmacy Prior Authorization Contacts (Coming Soon) Molina Complete Care Phone: (800) 424-5891 Fax: (844) 271-6887 ☐Pharmacy ☐Physical Therapy ☐Radiation Therapy ☐Speech Therapy ☐Transplant/Gene Therapy ☐Transportation ☐Wound Care ☐Other: P LEASE SEND CLINICAL NOTES AND ANY SUPPORTING DOCUMENTATION Primary ICD-10 Code: Ohio Prior Authorization Request Form Molina Healthcare Pharmacy Authorizations: Phone: 1 (844) 826-4335. 2025. Members are allowed 20 visits per therapy per calendar year without an authorization. E. If you have an emergency, always call 911. . imlb xmtt rmjfv knsb zgovui xyfaklc kdjibdw jmwzyq dhmwa ceu

Passport by molina pharmacy prior authorization form. Are you sure? ok cancel.