Frequently Used Forms

Recoupments and Reimbursements

MSCAN

	Physician Administered Drugs Prior Authorization Form
	Prior Authorization LookUp Tool
	Prior Authorization Pre-Service Review Guide & Request Form
	Behavioral Health Prior Authorization Form
	Gainwell Pharmacy Prior Authorization Form
	Q1 2025 Prior Authorization Mississippi Code/Benefit Exceptions
	Q1 2025 Prior Authorization Matrix
	Q2 2024 Prior Authorization Mississippi Code / Benefit Exceptions
	Q2 2024 Prior Authorization Matrix
	Q3 2024 Prior Authorization Mississippi Code/Benefit Exceptions
	Q3 2024 Prior Authorization Matrix

CHIP

	Physician Administered Drugs Prior Authorization Form
	Prior Authorization LookUp Tool
	Prior Authorization Pre-Service Review Guide & Request Form
	Behavioral Health Prior Authorization Form
	Gainwell Pharmacy Prior Authorization Form
	Q1 2025 Prior Authorization Mississippi Code/Benefit Exceptions
	Q1 2025 Prior Authorization Matrix
	Q2 2024 Prior Authorization Mississippi Code / Benefit Exceptions
	Q2 2024 Prior Authorization Matrix
	Q3 2024 Prior Authorization Mississippi Code/Benefit Exceptions
	Q3 2024 Prior Authorization Matrix

Medicaid Prior Authorization Annual Reporting

SB 2140 Mississippi Prior Authorization Annual Reporting

2024 Calendar Year

Line of Business: Medicaid

Prior Authorization Statistics	Percentage
The percentage of STANDARD Prior Authorization requests that were approved, aggregated for all items & services	99.6%
The percentage of STANDARD Prior Authorization requests that were denied, aggregated for all items & services	0.4%
The percentage of Prior Authorization requests that were Approved After an Appeal, aggregated for all items & services	15.5%
The percentage of Prior Authorization requests for which the review timeframe was Extended, and request was Subsequently Approved, aggregated for all items & services	85.7%
The percentage of EXPEDITED Prior Authorization requests that were Approved, aggregated for all items & services	94.8%
The percentage of EXPEDITED Prior Authorization requests that were Denied, aggregated for all items & services	5.2%
	Timing
Average time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	0.10
Median time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS)	0.05
Average time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	13.8
Median time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS)	8.4

A list of all health care services, including medications, that are subject to prior authorization can be found on our Prior Authorization Lookup page.

Reconsiderations and Appeals

Pregnancy

Other Forms and Resources

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	Prior Authorization LookUp Tool
	Prior Authorization Request Form (Coming Soon)
	Behavioral Health Prior Authorization Form (Coming Soon)
	Prescription Prior Authorization Form (Coming Soon)

	Provider Information Update Form
	Practitioner Enrollment Application
	Disclosure of Ownership and Control
	Provider Contract Request Form

	Community Connector Referral Form
	Request to Change Primary Care Provider
	Weight Watcher Referral Form
	Discharge Planning Checklist

Molinalogo

Frequently Used Forms

Provider Contracting and Credentialing

Recoupments and Reimbursements

Prior Authorizations

MSCAN

CHIP

Medicaid Prior Authorization Annual Reporting

Reconsiderations and Appeals

MSCAN

CHIP

Pregnancy

MSCAN

CHIP

Other Forms and Resources

MSCAN

CHIP

MSCAN

CHIP

MSCAN

CHIP

	Prior Authorization LookUp Tool
	Prior Authorization Request Form
	Behavioral Health Prior Authorization Form
	Prescription Prior Authorization Form

	Claim Reconsideration Request Form
	Pre-Service Appeal Request Form

	Claim Reconsideration Request Form
	Pre Service Appeal Request Form

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Frequently Used Forms

Provider Contracting and Credentialing

Recoupments and Reimbursements

Prior Authorizations

MSCAN

CHIP

Medicaid Prior Authorization Annual Reporting

Reconsiderations and Appeals

MSCAN

CHIP

Pregnancy

MSCAN

CHIP

Other Forms and Resources

MSCAN

CHIP

Information

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