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Provider Forms

​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 1/1/2020​
Medicaid/MMP Medicaid Prior Authorization (PA) Code List – Effective 1/1/2020
Medicare/MMP Medicare Prior Authorization (PA) Code List – Effective 1/1/2020
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
Hospital/Private BH Practice PA Form
Hospital/Private BH Practice Reference Guide
Behavioral Health Respite Services PA Reference Guide
Psychological Testing Request
Medicaid/MyCare Authorization Form – Community Behavioral Health

 

Prior Authorization Reconsiderations and Appeals

Authorization Reconsideration Form
Appeal Representative Authorization

Did you know a PA Denial Reconsideration is faster than an appeal in most cases? The Appeal Representative Authorization form is not required when requesting a reconsideration.


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 Request Form
Pharmacy Opiate 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
Prenatal Risk Assessment Form
PRAF 2.0 Instructions
In-Home Postpartum Assessment Form
ODM Health Insurance Fact Request Form


Non-Contracted Practice/Group Information

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


*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 Practices/Groups Making Changes

Provider Information Update Form*
CMHC-SUD BH Rendering Provider Template
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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