Molinalogo

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.

Authorizations / Utilization Management Forms

Prior Auth LookUp Tool

Prior Authorization Requests

Molina Healthcare aims to reduce your workload and administrative burden. Did you know you can submit Service Authorization requests through Availity using Molina’s Payer Spaces?

Submission of service authorization requests through Availity Essentials portal in Molina's Payer Spaces is quick and easy and should be your primary method to obtain authorizations. Registered Availity Essentials users have 24/7 access to submit service requests. Provider benefits include:

• Opportunity to receive an expedited real-time approval through Cite AutoAuth for certain services to begin treatment or provide services right away
• Easily attach medical records
• Check approval status and view the history of your request
• Enter multiple service authorization requests with improved navigation
  
  

Link to Availity Essentials: Here

If there are issues using Availity please fill out the following form and fax

• Prior Authorization Request Form and Instructions
  
  

Prior Authorization Code Lists

• Prior Authorization (PA) Code List – Effective 7/1/2024
  

Prior Authorization Reconsiderations and Appeals

• Appointment of Representative Form
  
  

Claims Forms

• Provider Reconsideration Review Request Form (PRR)

Provider Network Forms

• Disclosure of Ownership and Control
• Health Delivery Organization (HDO) Credentialing Form
• Provider Contract Request Form
• Practitioner Credentialing Form
• Provider Information Update Form
• W-9

Pharmacy Forms

• Prior Authorization Request Form and Instructions
• New Mexico Synagis Prior Authorization Form

Women’s Health Services

• Pregnancy Notification Form