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

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

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 & Request Form - Medicaid


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 Pharmacy Prior Authorization/Medication Exception Request Form - Medicaid


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


Other Resources

To access the ID Sterilization Consent Form, please visit the Idaho Department of Health and Welfare's website by clicking here


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

Adobe Acrobat Reader is required to view the file(s) above. Download a free version.