Box 4004, Bothell WA 98041-4004 . (2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be: (b) Meet the requirements of WAC 182-550-2301. Molina Healthcare | OneHealthPort Contact the managed care plan directly for instructions on how to submit an authorization request. The bariatric liquid diet pre-op diet is likely to be difficult for the patient to get through, though it is a must for surgery. Information marked with an asterisk (*) is required for processing. InterQual 2018.2 CP: Procedures Bariatric or Metabolic Surgery Adolescent/Adult . In this web site, the Molina Clinical Policy is made handy to you to guide you to your medical choices. Attention: Service Requests PO Box 349020 Columbus, Ohio 43234-9020 Providers are encouraged to use the Molina Healthcare of Ohio Service Request Form. Our Surgical Weight Management Program at OhioHealth Vraylar Prior Authorization Form. At Molina Healthcare, our coverage is designed around you, with plans to fit your needs. We do not accept the following insurance carriers at this time . 4 The term "bariatric surgery" refers to a collective group of procedures that involve modifications to the digestive system that promote weight loss, and include gastric bypass, gastric banding, sleeve gastrectomy, and biliopancreatic diversion (with or without duodenal switch) (National Institutes of Health, 2009). Stage 2 Bariatric Services is the pre-surgery phase, which includes a required six-month period of evaluation of the member before bariatric surgery is considered. Preauthorization Information Molina Marketplace of Mississippi Pulmonary Arterial Hypertension (PAH) Agents Prior Authorization Form. 10/eleven/2007 . Weight Lost: 78 lbs. Services - Rodolfo Molina M.D. | Molina Psychiatric Associates Dr. Martin del Campo is a board certified general surgeon and fellowship- trained bariatric surgeon. Revision of Bariatric Surgery Medically necessary surgery to correct complications from the initial bariatric surgery will be reviewed on an individual basis. Molina Healthcare offers a Weight Management Program to support the weight management and health nutrition needs of your adult patients, age 18 and older (excluding those members scheduled for bariatric surgery). For questions about Availity, including registration and training, contact Availity at 1.800.282.4548. Bariatric Surgery Program CARESOURCE, MOLINA, other Medicaid HMO'S (such as UHC Community Plan, Paramount Advantage, Buckeye Health) Insurance Information for Prior Authorization for Bariatric Surgery PLEASE BEGIN WORKING WITH YOUR PRIMARY CARE PHYSICIAN ON YOUR REQUIRED WEIGHT MANAGEMENT PROGRAM PRIOR TO SCHEDULING EVALUATIONS. Head & neck cancer, oropharyngeal cancer & thyroid cancer. Lipectomy or Panniculectomy Subsequent to Bariatric Surgery . Bariatric Surgery . Transmucosal Buprenorphine Prior Authorization Form. Collagen Vs Other Protein Sources. Dr. Fernando Molina, MD is a family medicine specialist in Rome, GA and has been practicing for 29 . In following years he moved to the United Kingdom where he continued training as a Specialist in General Surgery. PDF Bariatric Surgery - Community Plan Medical Policy I have Molina and I jumped threw all of the hoops, I did the over achiever thing and I was approved for surgery last week and I'm scheduled for November 23. Referrals to local classes can be made, if classes are offered. Please complete this form and submit your request online using our Prior Authorization and Notification tool on Link with all PCP BARIATRIC REFERRAL LETTER OF MEDICAL NECESSITY Date: Kurt W. Sprunger, MD, FACS Phoenix Bariatric Center, PLC 3805 E Bell Rd, Suite 5300 Phoenix, AZ 85032 Ph 602 422 9690 Re: Dear Dr. Sprunger,. Dr. Carlos Molina Navarro gained his diploma in Medicine and Surgery at the University of Malaga in 1990. (1) The agency covers medically necessary bariatric surgery for eligible clients. 215. Non-compliance with medical treatment. $99 for entire year supply of "1 per Day!" Bariatric Multivitamins! PROVIDER INFORMATION Correcting the Sterilization Consent Form . Dr. Molina is a board-certified psychiatrist with over 25 years of experience improving lives and treating mental health conditions, specializing in the treatment of mood disorders. After January 1, 2015, clients requesting the bariatric surgery program will need to request authorization for stages 2 and 3 from the client's assigned managed care plan. Revisional Bariatric Surgery: Conversion - A second bariatric procedure that changes the bariatric approach from the index procedure to a different type of procedure (e.g., sleeve gastrectomy or adjustable gastric band converted to Roux-en-Y [RYGB]). * Important Note: For best results, use Internet Explorer v11 or above to open HFS Medical forms. Please choose one Molina member Possible future member Health Care Professional Community based organization. (844) 461-2831. Our friendly, knowledgeable coordinators will be happy to answer your questions and to schedule your initial consultation with Dr. Alejandro Lopez. What I'm talking about here is very different. STAGE 2 Bariatric Surgery Request Please fax completed form to Fax: 1-855-678-6980. After graduating and receiving his medical degree from the University of Texas Medical Branch at Galveston, Dr, Molina went on to work with countless patients in . Contact Us. Financing/Payment Options Financing Options Vertical Sleeve Gastrectomy starting at $8999* Best Option- Self pay Special $7999* all-inclusive!! Sunshine Health must approve in advance the services listed below. Minimally invasive, laparoscopic surgery produces great success in patients with the following issues:u0003. 6 month physician supervised diet to include: Monthy weigth-in for consecutive months (No skipping Months). Additional Resources: For questions about this change, contact Molina Healthcare at 1.855.322-4082. Gallbladder cancer, gastroesophageal reflux disease, and benign pancreatic . Forms Eligibility Criteria . Type of diet must be notated. Dr. Molina frequently treats Psychiatric Evaluation, Psychological Evaluation, and Psychological Evaluations Prior to Bariatric Surgery . We are 100% against any type of hidden or undisclosed fees. Revision Bariatric Surgery Spring, Cypress, Woodlands and Houston If you have already undergone bariatric weight loss surgery, but have since regained too much of the weight you lost, you may be frustrated and discouraged. Goal Weight: 135 lbs. Find helpful forms for Molina Healthcare members such as medical release forms, appeals request forms and more. You still have a chance to get back to a healthy weight and lifestyle. ***Bariatric services are a complicated insurance benefit, let our patient facilitator Kairn Dodge, with her 14 years' experience, help you navigate this difficult first step. Bariatric surgery may be prior authorized when the patient meets all of the following criteria: The patient is a female at least 13 years of age and menstruating, or a male at least 15 years of age. Please use the following form to contact us. The Prior Approval Unit handles durable medical equipment, therapeutic supplies, mobility devices, therapies, home health, and bariatric surgery request for the Illinois Department of Health Care & Family Services. Our free Surgical Weight Management Seminar can get . 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