Medicare AdvantageAdministrativeMedium impact
Provider Bulletin 06-13-2025 2025 Annual Clinical Hierarchy IM IE LA OC SAC SD
Molina Healthcare·CA·Provider Bulletin
Effective date
Jun 13, 2025
We identified it
Jun 19, 2026
Summary
Molina Healthcare of California has updated their 2025 Annual Clinical Hierarchy that establishes the decision-making criteria for medical necessity determinations across Medicare, Medi-Cal, and Marketplace plans. This policy defines the order of evidence sources that providers and utilization management teams must follow when making coverage decisions, including federal regulations, coverage determinations, clinical guidelines, and specialty criteria.
Action Required
By June 13, 2025: Review and familiarize all clinical and billing staff with the Annual Clinical Hierarchy criteria expectations based on your contracted lines of business with Molina Healthcare of California. Ensure utilization management processes align with the specified hierarchy for Medicare (NCDs, LCDs, MCG criteria), Medi-Cal (state regulations, DHCS directives), and Marketplace (ACA requirements, InterQual criteria) plans. No immediate system changes required, but staff should understand the evidence hierarchy for coverage decisions.