Molinalogo

Healthcare Services Forms: 

Health Education Referral Form

Disease Management/Case Management Referral Form

Delivery Notification Form

Neonatal Transfer Form

Pregnancy Notification Report

Abortion Statement  ***

SBIRT Integrated Screening Tool

 

Prior Authorization Forms: 

Universal Prior Authorization Form BabyNet

MCO Universal Prior Authorization Newborn Form

BH Prior Authorization-Outpatient Treatment-Higher Level of Care Form  

Prior Authorization Request Form

Prior Authorization Medications Form

Advanced Imaging Prior Auth Guide

Sunset of Legacy Authorization Notice

Provider Network/Credentialing Forms: 

Credentialing Checklist

Credentialing Packet

Practice Demographics Form

Provider Change Form

Primary Care Provider Change Request Form

Contract Request Form

Facility HDO Form

Attachment C Provider Roster

SCDHHS Ownership Form  ***

Non Medicaid Enrolled Ownership Disclosure Form

Claims Forms and Documents: 

Provider Recovery Reversal Permission Form

Claims Workflow Infographic

Provider Updates:

POD Data Verification Fax

HealthMap General Provider Notice Fax

Pharmacy Timeliness PA Changes Fax

Fax Size Submission

Progeny Provider Notification

Nursing Facility Admissions Update

Advanced Imaging Fax

Legacy Portal Sunset

CMS-0057 Prior Authorization Annual Reporting

  2025 Prior Authorization Guide

  Prior Authorization Lookup Tool

 

South Carolina Medicaid Prior Authorization Report 2025

Prior Authorization Statistics Molina Healthcare Inc Percentage The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 73% The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 27% The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 18% The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 16% The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 58% The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 50% The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 89% The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 11% Timing Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 8 Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 9 Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 21 Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 20 *** SCDHHS STATE MANDATED REQUIRED FORMS FOR SUBMISSION