Please click on a form below to view a PDF printable version.
The files below are in PDF format ()
Claims
Provider Dispute Resolution Request Form
Prior Authorizations
Behavioral Health Prior Au...
Appeals
Grievance Consent Form
Provider Appeal Form
Behavioral Health
Behavioral Health Prior Authorization Form
Combined MCE Behavioral Health Provider Primary Care Provider Communication For...
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.
Authorizations / Utilization Management Forms
Prior Auth LookUp Tool
Prior Authorizatio...
Prescription Drugs & Medication
Molina Healthcare covers all medically necessary Medicaid-covered medications. We also use a preferred drug list (PDL). These are the drugs that we prefer our provider...
Please click on a form below to view a PDF printable version.
The files below are in PDF format ()
Provider Contracting
Contract Request Form
Provider Demographics
Change of Information Form
P...
One of the goals of Molina Healthcare Utilization Management (UM) department is to render appropriate UM decisions that are consistent with objective clinical evidence. To achieve that goal, Molina He...
Claim Management for Missing or Incorrect Member Information Effective December 7, 201801/03/19Molina Healthcare would like to notify our provider partners of a change to the management of claims subm...
Claim Management for Missing or Incorrect Member Information Effective December 7, 201801/03/19Molina Healthcare would like to notify our provider partners of a change to the management of claims subm...
