Molinalogo

Frequently Used Forms

Molina Allowed In-Office Lab Test List, Effective 1.1.19

Texas Standard HCS PA Form- CHIP/Marketplace Members (effective 09/01/2015)

Health Education Referral Form

Obstetrical Service Request Form

Disease Management Referral

Psychiatric Inpatient Discharge Form

Notification of Authorized Services Form

Change of Information Form

Claims Inquiry/Appeal Form

Contract Request Form

Credentialing Verification Organization (CVO) Provider FAQ

Texas Health Steps Provider Forms

Adult Foster Care Member & Provider Agreement

Prior Authorization

 Provider News Bulletin Prior Authorization Code Matrix - August 2020
  Provider News Bulletin Prior Authorization Code Matrix - May 2020
  Provider News Bulletin Prior Authorization Code Matrix - March 2020
  Provider News Bulletin Prior Authorization Code Matrix - January 2020
  Provider News Bulletin Prior Authorization Code Matrix - November 2019
  Provider News Bulletin Prior Authorization Code Matrix - January 2020 Updates
  Behavioral Health Service Request Form
  Texas Standardized Prior Authorization Form for Prescription Drugs
  Texas Standardized Prior Authorization Request Form for Healthcare Services
  Medicaid Prior Authorization Guide
  Medicaid Prior Authorization Code Matrix
  Historical Prior Authorization Code Matrix Update Log
  Medicaid Turn Around Times for Service Determinations

Claims

Provider Information

Provider Services Look up Tool

Provider Services Look Up Tool - Nursing Facility

Behavioral Health Post-Partum Depression Toolkit

Assessing for Behavioral Health – A Medical Clinician Guide

Screening for IDD – A Medical Clinician Resource

STAR Quick Reference Guide

STAR+PLUS Quick Reference Guide

CHIP and CHIP Perinate Quick Reference Guide

Provider Services & Service Coordination Contact Sheet

LTSS & Home and Community Based Services Quick Reference Guide

Depression Screening- Provider Tip Sheet

TMHP Timely Filing Calendar

*Please visit the EDI section for ERA/EFT enrollment forms

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