Molinalogo

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Claims
 Provider Dispute Resolution Request Form 

Prior Authorizations
 Behavioral Health Therapy Prior Authorization Form (Autism)
 Applied Behavior Analysis Referral Form
 Community Based Adult Services (CBAS) Request Form

 Molina ICF/DD Authorization Request Form
 HS-231 Certification for Special Treatment Program Services Form
 DHCS 6013 A Medical Review/Prolonger Care Assessment Form

 Q2 2024 PA Code Matrix 
 Q1 2024 PA Code Matrix
 Q4 2023 PA Code Matrix
 Q3 2023 PA Code Matrix
 Q2 2023 PA Code Matrix
 Q1 2023 PA Code Matrix
 Q4 2022 PA Code Matrix
 Q3 2022 PA Code Matrix
 Q2 2022 PA Code Matrix
 Q1 2022 PA Code Matrix
 Q4 2021 PA Code Matrix
 Q3 2021 PA Code Matrix
 Q2 2021 PA Code Matrix
 Q1 2021 PA Code Matrix

 Continuity of Care Form
 Prior Authorization 2021 Guide
 Prior Authorization 2022 Guide
 Prior Authorization 2022 Guide v2
 Prior Authorization 2023 Guide
 Prior Authorization 2024 Guide

Referral Forms
 CS Short-Term Post-Hospitalization Housing Referral Form
 CS Respite Services – Home Referral Form
 CS Day Habilitation Programs Referral Form
 CS Recuperative Care Referral Form
 CS Personal Care and Homemaker Services Referral Form
 CS Medically Tailored Meals Referral Form
 CS Housing Transition Navigation Referral Form
 CS Housing Tenancy and Sustaining Referral Form
 CS Housing Deposits Referral Form
 CS Community Transition Services Referral Form
 CS Asthma Remediation Referral Form
 CS Environmental Accessibility Adaptations – Home Modification Referral Form
 CS Environmental Accessibility Adaptations – Home Modification Physician Form
 CS Transition to Assisted Living Facilities or Residential Care Facilities Referral Form
 Pregnancy Referral Form
 Care Management Referral form
 Behavioral Health Coordination of Care Form
 Enhanced Care Management Member Referral Form
 Community Health Worker Referral Form
 Housing Specialist Referral Form

Transportation
 Physician Certification Statement

Pharmacy
 Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
 Prescription Drug Prior Authorization Request Form

Other Forms and Resources
 Provider Information Data Form
 ICE Roster Template

Medi-Cal Non-Covered Services
 Member Grievance Form (English)
 Member Grievance Form (Spanish)
 Member Grievance Form (Arabic)
 Member Grievance Form (Chinese)
 Member Grievance Form (Hmong)
 Member Grievance Form (Russian)
 Member Grievance Form (Vietnamese)
 Member Grievance Form (Tagalog)
 Member Grievance Form (Farsi)
 Allowed In-Office Lab Test List, effective 5-15-2018

Health Education Forms

 Health Education Referral Form
Health Management Services Flyer (for Members only) ( English |  Spanish |  Arabic |  Vietnamese)
 Health Education Services Provider Resources Flyer (for Providers only)

Cultural & Linguistic Services Forms
Member Resources for Cultural and Linguistic Services ( English |  Spanish |  Arabic)
Provider Resources for Cultural and Linguistic Services ( English)

Smoking Cessation Resources

 CA Quits Toolkit - A Guide to Integrate Tobacco Treatment into Health Systems
 Support Groups and Classes
 ACOG Guidelines – Smoking Cessation During Pregnancy

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