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Medical Services, Procedures and Devices Prior Authorization

Molina Healthcare of Utah requires prior authorization of some medical services, medical procedures and medical devices.  It is important to remember that: UM decision making is based only on appropriateness of care, service and existence of coverage. Molina Healthcare 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.

Provider Services


icon PDF NEW - Provider Orientation 2016
icon PDF NEW - Corrected Claims Tip Sheet
icon PDF Provider Welcome Packet
icon PDF New provider wants to join the Molina network
icon PDF Contracted provider wants to add a practitioner to an existing group contract
icon PDF Contracted provider wants to add a facility
icon PDF Contracted provider wants to update demographics
icon PDF Contracted provider needs to be terminated


Prior Authorization

Please click the links below to view documents related to Prior Authorization Requirements.

icon PDF 2016 MHU Codification List- Update eff 10/01/2016
icon PDF 2015 Form to Request Prior Authorization for Medical Services and Procedures (Medicaid-CHIP)
icon PDF 2016 Form to Request Prior Authorization for Medical Services and Procedures (Medicaid-CHIP)
icon PDF 2016​ Prior Authorization for Hep C Medication
icon PDF 2016 MHU Codification List
icon PDF Codes Requiring Prior Authorization Update - Over 900 Codes Removed
icon PDF Codes Removed from Prior Authorization Requirement

Please find all Medicare forms on the molinamedicare.com website.

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.

icon PDF Form to Request Prior Authorization for Medicaid/CHIP Pharmacy
icon PDF Updated Guidance for b Prophylaxis
icon PDF Synagis 2015-16 Prior Authorization form

Provider Appeal Request (Medicaid/CHIP)

Molina Healthcare of Utah allows the provider 90 days from the date of denial to file an appeal.  The appeal can be submitted by fax or by mail. The fax number and mailing address are included on the form below.

icon PDF Provider Appeal Request Form (Medicaid/CHIP)

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

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