Frequently Used Forms
Making Changes? Please notify Molina Healthcare at least 30 days in advance when you:
- Change office location, hours, phone, fax, or email.
- Add or close a location.
- Add or terminate a provider.
- Change in Tax ID and/or NPI.
- Open or close your practice to new patients (PCPs only).
The files below are in PDF format.
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Monthly Rate/Fee Schedule
Updates
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Authorization Requests
Prior Authorizations Preservice Review Guide & Request Forms
Home Health and Outpatient Therapy Prior Authorization Form
Pharmacy Prior Authorization Form
2026 Q1 Prior Authorization Codification List
2026 Q1 Prior Authorization Codes - Discontinued
2025 Q4 Prior Authorization Codification List
2025 Q4 Prior Authorization Codes - Discontinued
2025 Q3 Prior Authorization Codification List
2025 Q3 Prior Authorization Codes - Discontinued
2025 Q2 Prior Authorization Codification List
2025 Q2 Prior Authorization Codes - Discontinued
2025 Q1 Prior Authorization Codification List
2025 Q1 Prior Authorization Codes - Discontinued
2024 Q4 Prior Authorization Codification List
2024 Q4 Prior Authorization Codes - Discontinued
Prior Authorization Codification List - 2024 - Q3
- Provider Relations Manager Maps
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Contracting & Provider
Forms
Molina Authorized Representative Designation Form
Molina Claim-Issue Template (download)
Health Delivery Organization (HDO) Form
Patient Change of Address Form
Provider Contract Request Form
Provider Information Update Form
Provider Memo: Change Healthcare/ECHO Health Payment Option
Provider Profile and EFT Registration Form
Supplier Setup Form (atypical providers)
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Training & Quick Reference
Guides
2023 Medicaid Redetermination FAQ
Availity Essentials Reference Guide
Critical Incident Reference Guide
Doula and Lactation Consultant FAQ
FQHC Encounter Clinic Billing Quick Reference Guide
Guide to HFS MEDI Eligibility Search
IDPH COVID-19 Paxlovid Checklist Tool for Prescribers
New Century Health Data Sheet, Cardiology
New Century Health Data Sheet, Oncology
New Century Health FAQ Quick Reference Guide
Roster Template Frequently Asked Questions
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CMS-0057 Prior Authorization
Annual Reporting
2025 Prior Authorization Guide
Prior Authorization Lookup Tool
Illinois Medicaid Prior Authorization Annual Report 2025
Prior Authorization Statistics Molina Healthcare IncPercentageThe percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 86% The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 14% The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 52% The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 69% 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. 64% 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. 74% The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 92% The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 8% 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) 2 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) 1 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) 20 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) 19