Molina Prior Authorization Form PDF Details

Navigating the ever-changing health insurance landscape can be a daunting challenge for many providers and their staff. The good news is that Molina Healthcare has created an easy to use Prior Authorization Form available online, to help make the process easier and more convenient than ever before. With this new streamlined form, providers have access to all of the information they need in order to complete authorization requests quickly and accurately. In this post we will explain how you can get started utilizing the Molina Prior Authorization Form so that you are able to effectively utilize quick turnaround times when submitting requested documents.

QuestionAnswer
Form NameMolina Prior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmolina pa form, molina prior auth form, molina prior authorization, molina prior authorization form

Form Preview Example

Molina Healthcare Prior Authorization Request Form

Phone Number: 1-866-449-6849 (Bexar, Harris, Dallas, Jeferson, El Paso & Hidalgo Service Areas) 1-877-319-6826 (CHIP Rural Service Area)

Fax Number: 1-866-420-3639

Member Information

Plan: ☐ Molina Medicaid ☐ Molina Medicare ☐ TANF ☐ Other

Member’s Name: _______________________________________________________ DOB: _________________________________

Member’s ID#: _________________________________________________________ Member Phone #: _______________________

Service Is: ☐ Elective/ Routine ☐ Expedited/Urgent*

*Deinition of expedited/urgent is when the situation where the standard time frame or decision making process (up to 14 days per Molina’s process) could seriously jeopardize the life or health of the enrollee, or could jeopardize the enrollee’s ability to regain maximum function.

Referral/Service Type Requested

Inpatient

Outpatient

☐ Home Health

☐ Surgical procedures

☐ Surgical Procedure

 

☐ ER Admits

☐ Rehab (PT, OT, & ST)

 

 

☐ SNF

☐ Diagnostic Procedure

☐ DME

☐ Rehab

☐ Chiropractic

 

 

☐ LTAC

☐ Wound Care

☐ In Oice

 

☐ Infusion herapy

 

 

 

 

 

Diagnosis Code & Description: __________________________________________________________________________________

CPT/HCPC Code & Description: ________________________________________________________________________________

Number of visits requested:____________________________________ Date(s) of Service: __________________________________

Please send clinical notes and any supporting documentation

PROVIDER INFORMATION

Requesting Provider Name: _____________________________________________________________________________________

Facility Providing Service: ______________________________________________________________________________________

Contact @ Requesting Provider’s: _________________________________________________________________________________

Phone Number: __________________________________________ Fax Number: _________________________________________

For Molina Use Only:

8992TX1011

How to Edit Molina Prior Authorization Form Online for Free

molina prior authorization can be filled out very easily. Simply use FormsPal PDF editing tool to get it done quickly. Our tool is continually evolving to deliver the very best user experience attainable, and that is because of our resolve for constant enhancement and listening closely to comments from customers. Getting underway is easy! All you have to do is take the following basic steps down below:

Step 1: Press the orange "Get Form" button above. It will open up our pdf tool so that you can begin filling in your form.

Step 2: With this advanced PDF editing tool, it's possible to accomplish more than merely fill in forms. Edit away and make your forms seem high-quality with customized textual content added in, or fine-tune the file's original content to perfection - all that comes with the capability to add stunning photos and sign the file off.

If you want to complete this PDF form, make sure you type in the required details in each and every field:

1. The molina prior authorization will require certain information to be inserted. Make sure the next blanks are finalized:

Filling out segment 1 in molina pa form pdf

2. After the last section is done, you need to include the essential specifics in Provider Information, Requesting Provider Name, Facility Providing Service, Contact Requesting Providers, Phone Number Fax Number, and For Molina Use Only in order to proceed to the next step.

Find out how to fill out molina pa form pdf part 2

As for Facility Providing Service and For Molina Use Only, make sure you take another look in this section. These are the most significant fields in this PDF.

Step 3: Look through everything you have entered into the blanks and then press the "Done" button. Right after setting up afree trial account with us, it will be possible to download molina prior authorization or send it via email right off. The PDF will also be available in your personal cabinet with your adjustments. FormsPal ensures your information privacy by having a secure method that in no way records or shares any kind of private data used. Be confident knowing your files are kept safe every time you use our editor!

Molina Prior Authorization Form isn’t the one you’re looking for?

Related Documents