Molina coverage determinations are based on each state's Medicaid benefit package. Molina administers coverage under state contracts but does not set benefit rules. Coverage for the same CPT code can differ across states. Verify every service against the member's specific state plan.
Before service: Verify coverage on Molina portal. Submit PA if required. Day of service: Re-verify eligibility. After denial: Request formal determination within 30-60 days. Molina responds within 30 days. If unfavorable: appeal within state deadline.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-50 | Non-covered service | Not in state Medicaid benefit | Verify state benefit before service |
| CO-167 | Diagnosis not covered | ICD-10 not covered under state plan | Check state Medicaid diagnosis coverage |
| CO-11 | Medical necessity | Service not deemed necessary | Include clinical documentation |
Challenge coverage determinations through Molina's appeal process. File within the state-specific deadline. Include state Medicaid benefit references showing the service is covered. After internal appeal, request a state fair hearing.
No. Each state's Medicaid program defines its own covered services. Molina administers these benefits under state contracts. A service covered in California may not be covered in Texas.
Log into the Molina provider portal, select the member's state, and check the covered services list. You can also call Molina provider services for real-time coverage verification.
Yes. Providers can request copies of Molina's clinical guidelines and coverage policies used in making determinations. Contact your state-specific Molina provider services number.
Altair verifies Molina state-specific coverage rules before every claim submission.