Molinalogo

Provider Contracting and Credentialing

• Disclosure of Ownership and Control Form
• Facility/HealthCare Delivery Organization (HDO)/Long Term Special Services (LTSS) Credentialing Application
• Healthcare Delivery Organization Form/Blank Attestation Form
• Group Roster Template
• Healthcare Delivery Organization Form/Blank Attestation Form
• Provider Contract Request Form
• Provider Information Update Form
• Request to Add New Provider Form

Prior Authorizations

• Cosmetic
• DME
• Home Health
• Inpatient
• KY Medicaid Pharmacy Prior Authorization Form
• KY Universal Prior Authorization Request Form
• Long-Term Care Fax Form
• Oncology Services Matrix
• Passport Evolent KY Provider Matrix
• Prior Authorization Code Matrix - Q2 2025
• Prior Authorization Code Matrix - Q3 2025
• Prior Authorization Code Matrix - Q4 2025
• Prior Authorization Code Matrix - Q1 2026 
• Prior Authorization Code Matrix - Q2 2026
• Prior Authorization Code Matrix - Q3 2026
• Prior Authorization Guide
• Prior Authorization LookUp Tool
• SUD Review Form
• Therapy

Appeals & Grievances

• Appointment of Representative Form
• Provider Appeal Form
• Provider External Independent Third-Party Review Form
• Provider Grievances Form

Behavioral Health Authorization Forms

• ABA Authorization Request Form
• Comprehensive Community Supports Authorization Request Form
• Concurrent Authorization Request Form
• Day Treatment Authorization Request Form
• H0038 H2027 Authorization Request Form
• Initial Inpatient Authorization Request Form
• TCM Authorization Request Form
• Therapeutic Rehabilitation Form

Other Resources

• Consent for Sterilization
• Healthy Rewards Information and Attestation Form
• Health Education and Care Management Referral Form
• Hysterectomy Consent Form
• KY DMS Microsoft Electronic Notice of Pregnancy (eNOP) form
• KY DMS Notification of Pregnancy
• KY Medicaid Commercial Bypass Codes
• KY Medicaid Commercial Bypass List
• KY Medicaid Commercial Insurance Coverage Provider Attestation Form
• KY Provider Early Reversal Permission Form
• Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial
• Medicaid Clinical Trial Attestation Form
• PCP Member Dismissal Form
• PRAPARE - Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences
• Request to Change Primary Care Provider

This report shows how prior authorization requests are handled, such as how many were approved or denied and how quickly decisions were made. For services that require prior authorization, refer to the Prior Authorization Guide.

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