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Frequently Used Forms

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The files below are in PDF format (pdf icon)
 

Claims

Corrected Claim Billing Guide

All State Molina Information

Request for Claim Reconsideration 

In-Office Laboratory Test List

In-Office Laboratory Test Archive

Medical Services

Synagis (RSV) Authorization


Behavioral Health

Hospital/Private BH Practice PA Form

Hospital/Private BH Practice Reference Guide


Prior Authorization

Authorization Reconsideration Form

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

Prior Authorization Codification 2014 - PA Drugs

PA Code List Archive

 

Home Health Care

Home Health Prior Authorization Quick Tips

 

Pharmacy

Pharmacy Universal Claim Form

Hepatitis Therapy Prior Authorization Request Form

Prior Authorization Request Form

 

Other Forms

Ohio Urine Drug Screen Prior Authorization (PA) Request Form

Medicaid and​ Marketplace Authorization and Claim Reconsideration Guide

PAC Provider Intake Form

Web Portal Administrator Change Form

Well Care-OB/GYN Service Coding Guide

Prenatal Risk Assessment Form

Return of Overpayment

Endometrial Ablation Procedures

Observation Level of Care FAQ

Pain Management Procedures

Provider Web Portal Quick Reference Guide
 

Non-contracted Providers Information

Non-Participating Provider Contract Request Form


Contracted Providers Making Changes

Provider Information Update Form

CAQH Provider Data Form

Ownership Disclosure Form

 

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