Get Wa Molina Healthcare Behavioral Health Authorization/notification Form 2019-2025
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How to fill out the WA Molina Healthcare Behavioral Health Authorization/Notification Form online
Navigating the WA Molina Healthcare Behavioral Health Authorization/Notification Form can be straightforward with the right guidance. This guide provides clear, step-by-step instructions to help you fill out the form efficiently and accurately.
Follow the steps to complete the form online:
- Click ‘Get Form’ button to access the form online and open it in your selected editor.
- Begin by filling out the member information section. Include the plan type, request type (initial or concurrent), date of request, and admit/start date of services. Provide the member's name, date of birth, member ID, and phone number.
- Designate the urgency of the service by checking either 'elective/routine' or 'expedited/urgent,' keeping in mind the definitions provided for each.
- In the provider information section, list the name and contact details of the person or facility sending the request. Include details of the treatment provider, along with their NPI or Provider Tax ID number.
- If applicable, include the name of the attending psychiatrist/prescriber and universal management (UM) contact details.
- Select the necessary prior authorization services by checking the relevant boxes, such as residential treatment or psychological testing, and provide the procedure codes and descriptions requested.
- For concurrent review, check the necessary boxes for services like acute inpatient hospitalization or withdrawal management, and state the length of stay requested and dates of service.
- Provide primary and additional diagnosis codes along with any psychosocial concerns. Include expected discharge date and progress toward the discharge plan.
- In the clinical documentation section, include any necessary information and rationale for utilizing out-of-network providers, as well as any relevant clinical information needed for service review.
- Review all the information filled out to ensure accuracy, and make any necessary adjustments.
- Once everything is filled out, you can save your changes, download, print, or share the completed form.
Complete your WA Molina Healthcare Behavioral Health Authorization/Notification Form online today.
To cancel your Molina Healthcare Washington coverage, you can contact their customer service directly. They provide guidance on the cancellation process, including applicable notices that you might need to submit. It's important to remember that if you are enrolled in Medicaid, discussing options with your case worker may also be beneficial, especially when using the WA Molina Healthcare Behavioral Health Authorization/Notification Form.
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