Forms and Documents

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Provider Manual

2024 Marketplace Provider Handbook

Download 2024 Marketplace Provider Handbook

2023 Marketplace Provider Handbook

Download 2023 Marketplace Provider Handbook

2022 Marketplace Provider Handbook

Download 2022 Marketplace Provider Handbook

2021 Marketplace Provider Handbook

Download 2021 Marketplace Provider Handbook

Prior Authorization

Prior Authorization LookUp Tool

Download Prior Authorization LookUp Tool

Q3 2024 Matrix

Q3 2024 Matrix

Q3 2024 Provider Authorization Guide/Service Request Form (Effective 7/1/2024)

Download Q3 2024 Provider Authorization Guide/Service Request Form (Effective 7/1/2024)

Q2 2024 Provider Authorization Guide/Service Request Form (Effective 4/1/24)

Download Q2 2024 Provider Authorization Guide/Service Request Form (Effective 4/1/24)

Q1 2024 Provider Authorization Guide/Service Request Form (Effective 1/1/24)

Download Q1 2024 Provider Authorization Guide/Service Request Form (Effective 1/1/24)

Provider Authorization Guide/Service Request Form (Effective: 7/1/2023)

Download Provider Authorization Guide/Service Request Form (Effective: 7/1/2023)

2020 Codification Document (Effective 07/01/20)

Download 2020 Codification Document (Effective 07/01/20)

Web Portal QRG

Download Web Portal QRG

2020 Provider Quick Reference Guide

Download 2020 Provider Quick Reference Guide

In-Office Tests List - Eff: 03/01/2020

Download In-Office Tests List - Eff: 03/01/2020

2020 Codification Document (Effective 4/1/2020))

Download 2020 Codification Document (Effective 4/1/2020))

2019 Codification Document (Effective 10/15/19)

Download 2019 Codification Document (Effective 10/15/19)

Provider Appeal/Dispute Form

Download Provider Appeal/Dispute Form

Molina In-Network Referral Form

Download Molina In-Network Referral Form

Provider Contract Request Form

Download Provider Contract Request Form

Telehealth/Telemedicine Attestation

Download Telehealth/Telemedicine Attestation

MFL 8 Prescription Limit Form

Download MFL 8 Prescription Limit Form

Child Health Check Up Billing and Referral Codes

Download Child Health Check Up Billing and Referral Codes

Pharmacy Prior Authorization/Exception Form - (Effective: 01/01/18)

Download Pharmacy Prior Authorization/Exception Form - (Effective: 01/01/18)

Pregnancy Notification Form

Download Pregnancy Notification Form

Frequently Used Forms

Announcements and Reminders