For Molina Members About Molina
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Provider Forms

Claims

Corrected Claim Billing Guide
Request for Claim Reconsideration
Dental Request for Claim Reconsideration – Please review the Dental Provider Manual
Return of Overpayment
In-Office Laboratory Test List
In-Office Laboratory Test Archive

 

Prior Authorizations

Molina Healthcare Prior Authorization Request Form and Instructions
Medicaid/MMP Medicaid/Marketplace Prior Authorization (PA) Code List – Effective 8/1/2018
Medicare/MMP Medicare Prior Authorization (PA) Code List – Effective 8/1/2018
Medicaid/MMP Medicaid/Marketplace Prior Authorization (PA) Code List – Effective 6/1/2018
Medicare/MMP Medicare Prior Authorization (PA) Code List – Effective 6/1/2018
Archived PA Code Lists
Standardized Prior Authorization Instructions
Standardized Prior Authorization Form
Synagis (RSV) Authorization
Hospital/Private BH Practice PA Form
Hospital/Private BH Practice Reference Guide
Behavioral Health Respite Services PA Reference Guide
Psychological Testing Request
Medicaid/MyCare Authorization Form – Community Behavioral Health

 

Prior Authorization Reconsiderations and Appeals

Prior Authorization Denial Reconsideration
Appeal Representative Authorization

Did you know a PA Denial Reconsideration is faster than an appeal in most cases? The Appeal Representative Authorization form is not required when requesting a reconsideration.


Home Health Care

Standardized Home Health Care Form
Standardized Nursing Facility Stay Form
Request for Termination Due to ECF Stay


Pharmacy

Pharmacy Prior Authorization Form
Pharmacy Universal Claim Form
Hepatitis Therapy Prior Authorization Request Form
Pharmacy Opiate Prior Authorization Form


Abortion, Hysterectomy and Sterilization

ODM Consent to Sterilization Form
Guidelines for Completing Consent to Sterilization Form
ODM Consent to Hysterectomy Form
Guidelines for Completing Hysterectomy Form
ODM Abortion Certification Form


Other Forms and Resources

Web Portal Administrator Change Form
Prenatal Risk Assessment Form
In-Home Postpartum Assessment Form
ODM Notification of Third Party Request for Release Form
ODM Health Insurance Fact Request Form

Ownership Disclosure Form


Non-Contracted Practice/Group Information

Non-Participating Provider Contract Request Form*
Non-Contracted Provider Billing Guidelines


*Providers requesting to contract for a new line of business.

Contracted Practices/Groups Making Changes

Provider Information Update Form*
BH Provider Form
CAQH Provider Data Form
Open Panel Form
Request to Change Provider Form


*Add/change/term information for contracted providers/groups.


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