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.
Please click the links below to view documents related to Prior Authorization Requirements.
2015 Form to Request Prior Authorization for Medical Services and Procedures (Medicaid-CHIP)
2015 Prior Authorization for Hep C Medication
2015 MHU Codification List
Codes Requiring Prior Authorization Update - Over 900 Codes Removed
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.
Form to Request Prior Authorization for Medicaid/CHIP Pharmacy
Updated Guidance for b Prophylaxis
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.
Provider Appeal Request Form (Medicaid/CHIP)
New provider wants to join the Molina network
Contracted provider wants to add a practitioner to an existing group contract
Contracted provider wants to add a facility
Contracted provider wants to update demographics
Contracted provider needs to be terminated
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