Forms and Documents

Forms and Documents

Provider Manual

2026 Marketplace Provider Manual

2025 Marketplace Provider Manual

2024 Marketplace Provider Manual

2023 Marketplace Provider Manual

Prior Authorization

2026 Q2 Marketplace Prior Authorization Code Matrix Update

2026 Q1 Marketplace Prior Authorization Code Matrix Update

2026 Q1 Marketplace Prior Authorization Code Matrix

2026 Prior Authorization Guide and Request Form

2025 Q3 Marketplace Prior Authorization Code Matrix

2025 Q2 Marketplace Prior Authorization Code Matrix

2025 Q1 Marketplace Prior Authorization Code Matrix

2024 Q4 Marketplace Prior Authorization Code Matrix

2024 Q3 Marketplace Prior Authorization Code Matrix

Prior Authorization LookUp Tool

Prior Authorization Request Contact Information

Behavioral Health Prior Authorization Form

Pharmacy Prior Authorization Form

The Pharmacy Prior Authorization Form can be used for physician administered drugs and pharmacy benefit requests

2025 Prior Authorization Request Form

2024 Prior Authorization Request Form

Provider News Bulletin: Q2 2025 Prior Authorization Code Matrix Update

Provider News Bulletin: Q1 2025 Prior Authorization Code Matrix Update

Provider News Bulletin: Q4 2024 Prior Authorization Code Matrix Update

Reconsiderations and Appeals

Claim Reconsideration Request Form

Preservice Appeal Request Form

Frequently Used Forms

Claims

Provider Contracting and Credentialing

Pregnancy

CMS-0057 Prior Authorization Annual Reporting

Prior Authorization 2025

2025 Prior Authorization Guide

Prior Authorization Lookup Tool

Marketplace Prior Authorization Annual Report 2025

Prior Authorization Statistics	Molina Clinical Services, LLC Percentage
The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services.	87%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services.	13%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services.	50%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services.	46%
The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services.	53%
The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services.	57%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services.	90%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services.	10%
	Timing
Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days)	5
Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days)	4
Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours)	25
Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours)	23

SB 2140 Mississippi Prior Authorization Annual Reportings

Mississippi Prior Authorization Annual Reportings

Molina Clinical Services, LLC

Prior Authorization Statistics	Molina Clinical Services, LLC Percentage
The percentage of STANDARD Prior Authorization requests that were approved, aggregated for all items & services	88.10%
The percentage of STANDARD Prior Authorization requests that were denied, aggregated for all items & services	11.90%
The percentage of Prior Authorization requests that were Approved After an Appeal, aggregated for all items & services	20%
The percentage of Prior Authorization requests for which the review timeframe was Extended, and request was Subsequently Approved, aggregated for all items & services	61%
The percentage of EXPEDITED Prior Authorization requests that were Approved, aggregated for all items & services	90.38%
The percentage of EXPEDITED Prior Authorization requests that were Denied, aggregated for all items & services	9.62%
	Timing
Average time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	2.67
Median time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	3.1
Average time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	14.84
Median time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	14.79

Molina Healthcare of Mississippi, Inc.

Prior Authorization Statistics	Molina Healthcare of Mississippi, Inc. Percentage
The percentage of STANDARD Prior Authorization requests that were approved, aggregated for all items & services	93.30%
The percentage of STANDARD Prior Authorization requests that were denied, aggregated for all items & services	6.70%
The percentage of Prior Authorization requests that were Approved After an Appeal, aggregated for all items & services	26.28%
The percentage of Prior Authorization requests for which the review timeframe was Extended and request was Subsequently Approved, aggregated for all items & services	57.22%
The percentage of EXPEDITED Prior Authorization requests that were Approved, aggregated for all items & services	92.66%
The percentage of EXPEDITED Prior Authorization requests that were Denied, aggregated for all items & services	7.34%
	Timing
Average time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	3.03
Median time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	2.26
Average time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	26.83
Median time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	23.61

A list of all health care services, including medications, that are subject to prior authorization can be found on our Prior Authorization Lookup page.