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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 Services

• Provider Contract Application
• Provider Information Change Form
  

Prior Authorization

Please click the links below to view documents related to Prior Authorization Requirements.

• Synagis Prior Authorization form 2020-2021
• 2021 Prior Authorization Guide - Utah Medicaid
• 2021 Q1 - Prior Authorization Code Matrix - Utah Medicaid
• 2021 Q2 - Prior Authorization Code Matrix - Utah Medicaid
• 2020 Prior Authorization Guide - Utah Medicaid
• 2020 Prior Authorization Code Matrix - 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.

• Medications for treatment of Chronic Hepatitis C Prior Authorization
• 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
  
  

Other Forms and Resources

• In Office Lab Test List
  
  

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.

• Provider Appeal Request Form (Medicaid/CHIP)
• Provider Appeals Submission Training - Web Portal

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