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.
To add, terminate, or make demographic changes to an existing provider in your group, please submit a completed Provider Roster to 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.
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 2022-2023
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 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.
Provider Appeal Request Form (Medicaid/CHIP)
Please find all Medicare forms on the Molina Medicare website.
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