Molinalogo

The files below are in PDF format ()

Health Education Referral Form

Claims Dispute Request Form​

Healthcare Services Leadership Contact List​

Provider Addition Roster

Submitting Electronic Data Interchange (EDI) Claims

CAHPS Provider Brochure

Provider Change Form

Prior Authorizations

2020 Prior Authorization Matrix - Effective 07/01/2020

2020 Prior Authorization Guide - Effective 07/01/2020

2020 Prior Authorization Guide - Medicare - Effective 07/01/2020

2020 Prior Authorization Matrix - Effective 04/01/2020

2020 Prior Authorization Guide - Effective 04/01/2020

Prior Authorization Guide - Medicare - Effective 04/01/2020

2020 Prior Authorization Matrix - Effective 01/01/2020

2020 Prior Authorization Guide - Effective 01/01/2020

Prior Authorization Guide - Medicare - Effective 01/01/2020

2019 Prior Authorization Matrix - Effective 10/01/2019

2019 Prior Authorization Guide - Effective 10/01/2019

Prior Authorization Guide - Medicare - Effective 10/01/2019

2019 Prior Authorization Matrix - Effective 07/01/2019

2019 Prior Authorization Guide - Effective 07/01/2019

2019 Prior Authorization Matrix - Effective 04/01/2019

2019 Prior Authorization Guide - Effective 04/01/2019

2019 Prior Authorization Matrix - Effective 01/01/2019

2019 Prior Authorization Guide - Effective 01/01/2019

Prior Authorization Forms

MI Medicaid Synagis Authorization Form

Drug Prior Authorization Form

MI-Alternative Level of Care Authorization Form

Prior Authorization Form

MI-OB Notification Form

Pay for Performance

HRA Form

HRA Form - Spanish Version

Case Management/Community Connectors

Community Connector Referral Guide

Community Connector Referral Form

Provider Forms

Home Health Patient Drive Groupings Model (PDGM) FAQs

Home Care FAQ

Provider Addition Roster

Provider Contract Request Form

Web Portal Administrator Change Form

2018 Cultural Competency Training Attestation

FAQ

My Asthma Action Plan Card

Physician Office Laboratory Tests

Molina Medicaid Authorized Representative Designation Form

Notification of Pregnancy

Provider Request to Change PCP Form

Provider Change Form Requirements and Guidelines

Provider Change Form

Consent for Sterilization

Certification for Induced Abortion

HRA Incentive

HRA Form

HRA Form - Spanish Version

Other Resources

Adult Foster Care (AFC) Reference Guide-Invoice Submission

Communications

Molina Coding Tips - Please click here.

Maternal Infant Health Program

Archive 2016 2016 Prior Authorization Code Matrix - eff 10/01/2016 2016 Prior Authorization/Pre-Service Review Guide - eff 01/01/2016 2017 Archived Forms 2017 Prior Authorization Matrix - effective 10/01/2017 2017 Prior Authorization Guide - effective 10/01/2017 2017 Prior Authorization Matrix - effective 07/01/2017 2017 Prior Authorization Guide - effective 04/01/2017 2017 Prior Authorization Code Matrix - Effective 04/01/2017 2017 Prior Authorization Code Matrix - eff 01/01/2017 2018 Archived Forms 2018 Prior Authorization Matrix - Effective 10/1/2018 2018 Prior Authorization Guide - effective 10/01/2018 2018 Prior Authorization Guide - effective 06/01/2018 2018 Prior Authorization Matrix - effective 06/01/2018 2018 Prior Authorization Matrix - effective 01/01/2018 2018 Prior Authorization Guide - effective 03/01/2018 ​​​​   The files below are in Excel format

MDCH Provider Forms and Other Resources Adobe Acrobat Reader is required to view the file(s) above. Download a free version.

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​