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Provider Forms

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Claims

Corrected Claim Billing Guide
All State Molina Information
Request for Claim Reconsideration
Dental Request for Claim Reconsideration – Please review the Dental Provider Manual
Return of Overpayment
In-Office Laboratory Test List ​​​​​​​​
In-Office Laboratory Test Archive

 
Prior Authorizations

Molina Healthcare Prior Authorization Request Form and Instructions
Marketplace Prior Authorization (PA) Code List – Effective 11/1/2019
Medicaid/MMP Medicaid Prior Authorization (PA) Code List – Effective 11/1/2019
Updated - Medicare/MMP Medicare Prior Authorization (PA) Code List – Effective 10/1/2019
Updated - Medicaid/MMP Medicaid Prior Authorization (PA) Code List – Effective 10/1/2019
Updated - Marketplace Prior Authorization (PA) Code List – Effective 10/1/2019
Updated - Medicare/MMP Medicare Prior Authorization (PA) Code List – Effective 7/1/2019
Updated - Medicaid/MMP Medicaid/Marketplace Prior Authorization (PA) Code List – Effective 7/1/2019
Archived PA Code Lists
Synagis (RSV) Authorization
Psychological Testing Request
Appeal Representative Authorization
Appointment of Representative Form
Hospital/Private BH Practice PA Form
Hospital/Private BH Practice Reference Guide
Behavioral Health Respite Services PA Reference Guide
 Medicaid/MyCare Authorization Form – Community Behavioral Health​
 Authorization Reconsideration Form

 

Home Health Care

MyCare Ohio Uniform Authorization Request Form
Request for Termination Due to ECF Stay

 

Pharmacy

Pharmacy Prior Authorization Form
Pharmacy Universal Claim Form
Hepatitis Therapy Prior Authorization Form

 

Abortion, Hysterectomy and Sterilization

ODM Consent to Sterilization Form
Guidelines for Completing Consent to Sterilization Form
ODM Consent to Hysterectomy Form
Guidelines for Completing Hysterectomy Form
ODM Abortion Certification Form

 

Other Forms and Resources

Ohio Urine Drug Screen Prior Authorization (PA) Request Form
PAC Provider Intake Form
Web Portal Administrator Change Form
ODM Health Insurance Fact Request Form
 Prenatal Risk Assessment Form
Pregnancy Rewards Provider Toolkit
 Notice of Medicare Non-Coverage

Non-Contracted Providers Information

Non-Contracted Provider Billing Guidelines Form
Ohio Provider Contract Request Form*

*For first-time providers wanting to contract with Molina Healthcare of Ohio (MHO), or for existing MHO providers wanting to add a new product to their contract.

 

Contracted Providers Making Changes

Provider Information Update Form*
CAQH Provider Data Form
Open Panel Form
Request to Change Provider Form
 Ownership Disclosure Form

 *Add/change/term information for contracted providers/groups

 

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