Molinalogo

Claims

Corrected Claim Billing Guide

Request for Claim Reconsideration Form (Non-Clinical Claim Dispute Form)

Dental Request for Claim Reconsideration – Please review the Dental Provider Manual

Return of Overpayment

In-Office Laboratory Test List

In-Office Laboratory Test Archive

Prior Authorizations

Molina Healthcare Prior Authorization Request Form and Instructions

Nursing Facility Request Form

Synagis (RSV) Authorization

Behavioral Health Respite Services PA Reference Guide

Psychological Testing Request

Medicaid Authorization Form – Community Behavioral Health

Prior Authorization Code Changes

Medicaid: Q1 2025 PA Code Changes

Medicare and MMP: Q1 2025 PA Code Changes

Marketplace: Q1 2025 PA Code Changes

Medicaid and Marketplace: Updated Q4 2024 PA Code Change with 12/1 Evolent Codes Impacted

Medicaid: Q4 2024 PA Code Changes

Medicare and MMP: Q4 2024 PA Code Changes

Marketplace: Q4 2024 PA Code Changes

Archived PA Code Lists and Changes

Prior Authorization Reconsiderations and Appeals

Authorization Reconsideration Form (Authorization Appeal or Clinical Claim Dispute Form)

Grievance/Appeal Request Form

Did you know a PA Denial Reconsideration is faster than an appeal in most cases?

Provider Contract Templates

Molina Healthcare Dental Provider Services Agreement

Molina Healthcare Hospital Services Agreement

Molina Healthcare Provider Services Agreement

Abortion, Hysterectomy and Sterilization

ODM Consent to Sterilization Form

Guidelines for Completing Consent to Sterilization Form

ODM Consent to Hysterectomy Form

ODM Abortion Certification Form

Other Forms and Resources

Critical Incident Referral Template (Medicaid Only)

Ohio Urine Drug Screen Prior Authorization (PA) Request Form

PAC Provider Intake Form

PRAF 2.0 and other Pregnancy-Related Forms

ODM Health Insurance Fact Request Form

Request for External Wheelchair Assessment Form

Non-Contracted Practice/Group Information

Ohio Dental Provider Contract Request Form
Ohio Provider Contract Request Form*
ODM Designated Provider and Non-Contracted Provider Guidelines
*For first-time providers wanting to contract with Molina Healthcare of Ohio (MHO), or for existing MHO providers wanting to add a new product to their contract.

Contracted Practices/Groups Making Changes

Provider Information Form*

CAQH Provider Data Form

Request to Change Provider Form

Ownership and Control Disclosure Form

*Add/change/term information for contracted providers/groups.

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