Forms and Documents

Forms and Documents

Provider Manual

2026 Marketplace Provider Handbook

2025 Marketplace Provider Handbook

Prior Authorization

2026 Provider Authorization Guide & Service Request Form (Effective 1/1/26)

Q1 2026 PA Code Matrix

Q2 2026 Provider Prior Authorization Code Matrix Update

Q1 2026 Provider Prior Authorization Code Matrix Update

Q3 2025 Provider Prior Authorization Code Matrix Update

Q2 2025 Provider Prior Authorization Code Matrix Update

2025 Provider Authorization Guide Service Request Form (Effective 1/1/25)

Q2 2025 PA Code Matrix

Q1 2025 PA Code Matrix

Prior Authorization LookUp Tool

Q3 2024 Provider Authorization Guide/Service Request Form (Effective 7/1/2024)

Q2 2024 Provider Authorization Guide/Service Request Form (Effective 4/1/24)

Q1 2024 Provider Authorization Guide/Service Request Form (Effective 1/1/24)

Provider Appeal/Dispute Form

Molina In-Network Referral Form

Telehealth/Telemedicine Attestation

MFL 8 Prescription Limit Form

Child Health Check Up Billing and Referral Codes

Pharmacy Prior Authorization/Exception Form - (Effective: 01/01/18)

Pregnancy Notification Form

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

Frequently Used Forms

Claims

Announcements and Reminders

Provider Communications, Tip Sheets, Billing Guidelines and Resource Guides