Frequently Used Forms


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The information change form has been replaced by the Provider Roster Template, which can be found under the "Forms" section of the Provider Portal.

Contract Request Form

 


Prior Authorization

Molina Healthcare of Utah requires prior authorization of some medical services, medical procedures and medical devices.  It is important to remember that: Utilization Management (UM) decision making is based only on appropriateness of care, service and existence of coverage. Molina 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.

Please click the links below to view documents related to prior authorization requirements.

2022 Prior Authorization Guide

2021 Pain Prior Authorization Guide & Request Form - Medicaid



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

Request Prior Authorization for Medicaid/CHIP Pharmacy

Request Opioid Prior Authorization for Medicaid Pharmacy

J-Code Prior Authorization form 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.

The appeal can also be submitted by fax or by mail. The fax number and mailing address are included on the form below.

Please find all Medicare forms on the Molina Medicare website.

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