Emergency Room Prior Authorization

SMITH, TEDDY

Member ID: *********

Member Name:

RxBIN:

RxPCN:

RxGRP:

004336

ADV

RX0823

PCP Address:

PCP Phone:

**** * **** ** *** 101

,EVERGREEN PARK IL 60805

708-***-****

PCP: KHAN, MOHAMMED SHAEZOR

DOB:

Effective Date:

HealthChoice Illinois

04/17/1981

05/01/2024

MyMolina.com

Members: To verify eligibility or change your Primary Care Provider (PCP) visit www.MyMolina.com or call Member Services 855-***-****. For those who are hearing impaired, call the Illinois Relay at 7

-1-1.

Emergency Services: Call 911 or go to the nearest emergency room or other appropriate setting. If you are not sure whether you need to go to the emergency room, call your PCP or call our 24-Hour Nurse Advice Line at 888-***-**** for English or 866-***-**** for Spanish. For those who are hearing impaired, call the Illinois Relay at 7-1-1. Behavioral Health: 24-Hour Crisis Hotline 888-***-****. For Spanish dial 866-***-****.

Transportation: To schedule a ride or for day-of ride assist, call 844-***-****.

Providers: To verify eligibility, claims status or prior authorization, call

855-***-****.

Prior Authorization: Required for all inpatient admissions and selected outpatient services. Call 855-***-**** to notify us of an admission. Pharmacists: For pharmacy questions, call 855-***-****. Dental and Vision: Dental 844-***-****, Vision 866-***-**** Claim Submission: P.O. Box 540, Long Beach, CA 90801 EDI Submissions: Payor ID 20934

MolinaHealthcare.com/Medicaid

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