Molinalogo

Provider Contracting and Credentialing

• Disclosure of Ownership and Control Form
• Practitioner Application Form
• Provider Contract Request Form
• Provider Information Update Form
• Healthcare Delivery Organization Form
• Group Roster Template

Prior Authorizations

• Behavioral Health Prior Authorization Form
• SUD Review Form
• Prior Authorization Code Matrix - Q3 2022
• Prior Authorization Guide
• Prior Authorization LookUp Tool
• Cosmetic
• DME
• Home Health
• Inpatient
• Therapy
• KY Universal Prior Authorization Request Form
• KY Medicaid Pharmacy Prior Authorization Form
• Long-Term Care Fax Form

Appeals & Grievances

• Provider Appeal Form
• Provider Grievances Form
• Provider Third-Party Review Form

Other Resources

• PCP Member Dismissal Form
• PRAPARE - Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
• Pregnancy Notification Report
• Request to Change Primary Care Provider
• Health Education and Care Management Referral Form