Medical Services, Procedures and Devices Prior Authorization
Molina Healthcare of Utah requires prior authorization of some medical services, medical procedures and medical devices. It is important to remember that: UM decision making is based only on appropriateness of care, service and existence of coverage. Molina Healthcare does not specifically reward providers or other individuals for issuing denials for care. UM decision makers do not receive incentives to encourage decisions that result in underutilization.
Provider Contracting and Credentialing
The information change form has been replaced by the Provider Roster Template, which can be found under the "Forms" section of the Provider Portal.
Please click the links below to view documents related to Prior Authorization Requirements.
- 2022 Prior Authorization Guide & Request Form
- 2021 Pain Prior Authorization Guide & Request Form - Utah Medicaid
Please find all Medicare forms on the Molina Medicare website.
Specialty Care Prior Authorization
Prior authorization and referrals are not required for members seeking care from participating Molina specialty physicians and providers. Prior authorization is required for members to seek care from specialty physicians and providers who are not members of the Molina network.
Pharmacy Prior Authorization
Molina Healthcare of Utah requires prior authorization of some medications, when medications requested are non-formulary and for high cost e medications. Please click the links below to view documents related to Prior Authorization Requirements.
- Synagis Prior Authorization form 2021-2022
- Form to Request Prior Authorization for Medicaid/CHIP Pharmacy
- Form to Request Opioid Prior Authorization for Medicaid Pharmacy
- Form to Request J-Code Prior Authorization for Medicaid Pharmacy
Provider Appeal Request (Medicaid/CHIP)
Molina Healthcare of Utah allows the provider 90 days from the date of denial to file an appeal.
A provider may now file an appeal ONLINE on the Provider web portal at : https://provider.molinahealthcare.com/Provider/Login The appeal can also be submitted by fax or by mail. The fax number and mailing address are included on the form below.
Other Forms and Resources
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