Provider Forms


adobe Corrected Claim Billing Guide
adobe Request for Claim Reconsideration Form (Non-Clinical Claim Dispute Form)
adobe Dental Request for Claim Reconsideration – Please review the Dental Provider Manual
adobe Return of Overpayment
adobe In-Office Laboratory Test List
In-Office Laboratory Test Archive

Prior Authorizations

adobe Molina Healthcare Prior Authorization Request Form and Instructions
adobe Nursing Facility Request Form
adobe Synagis (RSV) Authorization
adobe Behavioral Health Respite Services PA Reference Guide
adobe Psychological Testing Request
adobe Medicaid Authorization Form – Community Behavioral Health

Prior Authorization Code Lists

adobe Prior Authorization (PA) Code List - Effective 10/1/2023

adobe Prior Authorization (PA) Code List - Effective 7/1/2023

adobe Prior Authorization (PA) Code List - Effective 4/1/2023
Archived PA Code Lists

Prior Authorization Reconsiderations and Appeals

adobe Authorization Reconsideration Form (Authorization Appeal or Clinical Claim Dispute Form)
adobe Grievance/Appeal Request Form

Did you know a PA Denial Reconsideration is faster than an appeal in most cases?

Provider Contract Templates

adobe Molina Healthcare Dental Provider Services Agreement
adobe Molina Healthcare Hospital Services Agreement
adobe Molina Healthcare Provider Services Agreement

Home Health Care

adobe MyCare Ohio Uniform Authorization Request Form

Abortion, Hysterectomy and Sterilization

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

Other Forms and Resources

adobe Critical Incident Referral Template (Medicaid Only)
adobe Ohio Urine Drug Screen Prior Authorization (PA) Request Form
adobe PAC Provider Intake Form
adobe PRAF 2.0 and other Pregnancy-Related Forms
adobe ODM Health Insurance Fact Request Form
adobe Request for External Wheelchair Assessment Form

Non-Contracted Practice/Group Information

adobe Ohio Dental Provider Contract Request Form
adobe Ohio Provider Contract Request Form*
adobe ODM Designated Provider and Non-Contracted Provider 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

adobe Provider Information Update Form*
adobe CAQH Provider Data Form
adobe Request to Change Provider Form

adobe Ownership and Control Disclosure Form

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

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