Frequently Used Forms

 

Appeals

 Grievance Consent Form
 Provider Appeal Form

 

Behavioral Health

 Behavioral Health Prior Authorization Form
 Combined MCE Behavioral Health Provider Primary Care Provider Communication Form

 

Contracting & Provider Network

 Provider Contract Request Form
 Wisconsin W9
 Provider Roster Template
 Provider Information Update Form

 

Credentialing

 Molina Healthcare of WI- Practitioner Application
 Molina Healthcare Health Delivery Organization (HDO) application
 Molina Healthcare of WI CAQH Credentialing Checklist

 My Choice Wisconsin by Molina Healthcare Attestation Form

 LTSS Credentiaing 101

 LTSS Credentialing FAQ

 

 

Claims and Adjustments

 Overpayment Form
 

Prior Authorization

 Updated 10/1/24: 2024 PA Guide Request Form

 Q4 2024 Medicaid Prior Authorization Code Matrix

 Q3 2024 Medicaid Prior Authorization Code Matrix

 Q2 2024 Medicaid Prior Authorization Code Changes

 2024 PA Guide Request Form

 Q1 2024 Medicaid Prior Authorization Code Changes
 2023 PA Guide Request Form
 Q4 2023 Medicaid Prior Authorization Code Changes
 Q3 2023 Medicaid Prior Authorization Code Changes
 Q3 2023 Medicaid Prior Authorization Code Matrix
 Q2 2023 Medicaid Prior Authorization Code Changes
 Q2 2023 Medicaid Prior Authorization Code Matrix
 Q1 2023 Medicaid Prior Authorization Code Changes
 Q1 2023 Medicaid Prior Authorization Code Matrix
 2022 PA Guide Request Form
 Q1 2023 Medicaid Prior Authorization Code Changes
 Q4 2022 Medicaid Prior Authorization Code Matrix
 Q4 2022 Medicaid Prior Authorization Code Changes
 Q3 2022 Medicaid Prior Authorization Code Matrix
 Q3 2022 Medicaid Prior Authorization Code Changes
 PCW PA Request Form – Medicaid

 

Referral and Other Health Care Forms

 Peer to Peer and Provider Reconsideration Form
 Hospice Benefit Election Form
 National Diabetes Prevention Program Referral
 Authorization for Use and Disclosure of PHI
 Authorization for Use and Disclosure of PHI (Spanish)
 PNCC Provider Notification Form
 Case Management Referral Form
 Clinical Care Coordination Referral Form
 Pregnancy Notification Form 

 

Reference Guides

 Quick Reference Guide