Frequently Used Forms


Provider Contracting and Credentialing


To become a participating Molina provider, please submit a completed Contract Request Form and a current W-9 to MHUProviderContracting@MolinaHealthcare.com.

download arrow button Contract Request Form

download arrow button W-9 Form

To add, terminate, or make demographic changes to an existing provider in your group, please submit a completed Provider Roster to MHUPIM@MolinaHealthcare.com.

excel_icon Provider Roster

 

Prior Authorization

Molina Healthcare of Utah requires prior authorization of some medical services, medical procedures and medical devices.  It is important to remember that: Utilization Management (UM) decision making is based only on appropriateness of care, service and existence of coverage. Molina does not specifically reward providers or other individuals for issuing denials for care. UM decision makers do not receive incentives to encourage decisions that result in underutilization.

Please click the links below to view documents related to prior authorization requirements.

download arrow button 2024 Prior Authorization Guide


Specialty Care Prior Authorization

Prior authorization and referrals are not required for members seeking care from participating Molina specialty physicians and providers. Prior authorization is required for members to seek care from specialty physicians and providers who are not members of the Molina network.

 

Pharmacy Prior Authorization

Molina Healthcare of Utah requires prior authorization of some medications, when medications requested are non-formulary and for high cost e medications. Please click the links below to view documents related to Prior Authorization Requirements.

download arrow button Synagis Prior Authorization form 2023-2024

download arrow button Request Prior Authorization for Medicaid/CHIP Pharmacy

download arrow button Request Opioid Prior Authorization for Medicaid Pharmacy

download arrow button J-Code Prior Authorization form for Medicaid Pharmacy

 

Provider Appeal Request (Medicaid/CHIP)

Molina Healthcare of Utah allows the provider 90 days from the date of denial to file an appeal. A provider may now file an appeal online using the Molina Provider Portal or the Availity Essentials Provider Portal. To login to either portal, click here.

The appeal can also be submitted by fax or by mail. The fax number and mailing address are included on the form below.

download arrow button Provider Appeal Request Form (Medicaid/CHIP)

 

Please find all Medicare forms on the Molina Medicare website.

Adobe Acrobat Reader is required to view the file(s) above. Download a free version.