Molina Healthcare Services (HCS) Provider Guide

This document provides an overview of Molina Healthcare's Healthcare Services (HCS) program, focusing on Utilization Management (UM) and Care Management (CM). It outlines the integrated model designed to deliver high-quality, cost-effective, and medically appropriate care for members.

The manual details key functions and processes related to UM, including pre-service authorization, inpatient authorization, and medical necessity reviews. It also covers the principles of Care Management, emphasizing a member-centric approach to address diverse health needs and improve health outcomes.

Providers will find essential information on eligibility verification, benefit administration, UM decisions, medical necessity criteria, prior authorization procedures, and communication protocols. The guide aims to ensure efficient and effective coordination of care for all Molina members.

For more detailed information, providers are encouraged to visit the Molina Healthcare website or contact the UM Department directly.

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