Frequently Used Forms


Provider Contracting and Credentialing


To become a participating Molina provider, please submit a completed Contract Request Form and a current W-9 to MHUProviderContracting@MolinaHealthcare.com.

download arrow button Contract Request Form

download arrow button W-9 Form

To add, terminate, or make demographic changes to an existing provider in your group, please email MHUPIM@MolinaHealthcare.com.

 

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. 

download arrow button 2026 Prior Authorization Guide

Code Matrix Updates

download arrow button Code Matrix Updates - Q2 2026
download arrow button Code Matrix Updates - Q1 2026
download arrow button Code Matrix Updates - Q4 2025
download arrow button Code Matrix Updates - Q3 2025
download arrow button Code Matrix Updates - Q2 2025
download arrow button Code Matrix Updates - Q1 2025

download arrow button Utah Code Matrix/Benefit Exceptions - Effective Q1, 2025


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.

download arrow button Request Prior Authorization for Medicaid/CHIP Pharmacy

download arrow button Request Opioid Prior Authorization for Medicaid Pharmacy

download arrow button J-Code Prior Authorization form for Medicaid Pharmacy

 

Provider Appeal Request (Medicaid/CHIP)

Molina Healthcare of Utah allows the provider 60 days from the date of denial to file an appeal. A provider may now file an appeal online using the Molina Provider Portal or the Availity Essentials Provider Portal. To login to either portal, click here.

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

download arrow button Provider Appeal Request Form (Medicaid/CHIP)

 

CMS-0057 Prior Authorization Annual Reporting

download arrow button  2025 Prior Authorization Guide

download arrow button  Prior Authorization Lookup Tool

UTAH INTEGRATED CARE PLAN - NON-TRADITIONAL 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. 100%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 0%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
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. NA
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. NA
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 100%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 0%
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) 10
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) 2
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) 2

UTAH HEALTHY KIDS PLAN B 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. 82%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 18%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 67%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
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. 100%
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. NA
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 100%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 0%
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) 6
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) 6
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) 27
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) 19

UTAH INTEGRATED CARE PLAN - TRADITIONAL 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. 81%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 19%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 68%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 58%
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. 64%
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. 88%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 12%
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) 6
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) 6
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

UTAH URBAN MEDICAID TRADITIONAL - NO COPAY - NO COINS 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. 76%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 24%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 77%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 76%
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. 54%
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. 100%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 90%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 10%
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) 7
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) 6
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

UTAH URBAN MEDICAID TRADITIONAL - W/ COPAY - NO COINS 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. 80%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 20%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 83%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 0%
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. 100%
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. NA
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) 6
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) 6
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) 18
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) 19

UTAH HEALTHY KIDS PLAN C 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. 72%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 28%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 93%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
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. 100%
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. NA
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 94%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 6%
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) 7
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) 7
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) 19
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

Z UTAH URBAN MEDICAID NON-TRADITIONAL - NO COPAY - NO COINS 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. 50%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 50%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
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. NA
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. NA
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. NA
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. NA
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) 9
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) 7
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) NA
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) NA

UTAH HEALTHY KIDS PLAN C - N 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. 75%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 25%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. NA
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. NA
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. NA
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. NA
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. NA
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) 4
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) 3
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) NA
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) NA


 

Please find all Medicare forms on the Molina Medicare website.

Adobe Acrobat Reader is required to view the file(s) above. Download a free version.