Provider Forms


Provider Contracting and Credentialing


To become a participating Molina provider, please submit a completed Contract Request Form and a current W-9 to MHIDProviderContracting@MolinaHealthcare.com.

download arrow button Contract Request Form

To add, terminate, or make demographic changes to an existing provider in your group, please submit a completed Provider Roster to MHIDPNA@MolinaHealthcare.com.

excel_icon Provider Roster

 

Medical Services, Procedures and Devices Prior Authorization

Molina Healthcare of Idaho requires prior authorization of some medical services, medical procedures and medical devices.  It is important to remember that: Utilization Management (UM) decision making is based only on appropriateness of care, service and existence of coverage. Molina 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.

All General/Physical Health Prior Authorization Requests can be submitted via the Availity Essentials Provider Portal or via fax. Please click the links below to view documents related to prior authorization requirements.

download arrow button 2024 Prior Authorization Guide - Medicare/MMCP

download arrow button 2024 Prior Authorization Request Form - Medicare/MMCP

download arrow button 2024 Behavioral Health Prior Authorization Request Form - Medicare/MMCP

 

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 Idaho requires prior authorization of some medications, when medications requested are non-formulary and/or are high cost e medications.

All Pharmacy Prior Authorization Requests should be submitted via fax. Please click the link below to view document related to Pharmacy Prior Authorization requirements and requests.

download arrow button Synagis Prior Authorization form 2021-2022

download arrow button Pharmacy Prior Authorization/Medication Exception Request Form - Medicare/MMCP

 

Provider Appeal Request (Medicaid)

Molina Healthcare of Idaho allows the provider 60 days from the date of denial to file an appeal. Appeals can be be submitted via the Availity Essentials Provider Portal, fax or by mail. The fax number and mailing address are included on the form below.

download arrow button Provider Appeal Request Form

 

Please find all Medicare forms, including Prior Auth Code Matrices on the Molina Medicare website.

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