Molinalogo

If your Contract Request Form is accepted, our Provider Contracting department will provide you with credentialing and contracting documents that must be completed. Documents you receive may differ depending on provider type, and may include:

• - Provider Agreement;
• - Provider Information Form;


• - W-9;
• - Practitioner Application (if practitioner does not have an updated and attested CAQH profile); and/or
• - Health Delivery Organization Credentialing Application

Upon receipt of completed documents, Provider Contracting will then begin the credentialing process.

The final step will be for Molina to countersign your Provider Agreement and provide you with a signed copy. Credentialed facilities and/or practitioners will also be loaded into Molina’s claims payment system as in-network providers. The in-network effective date for each facility and/or practitioner will be the date of credentialing completion, which will be included in the notification that you will receive from Molina’s Credentialing department (referenced above in Step 3 – Credential).