Molina Healthcare Medicaid, CHIP, & Medicare of Texas 2025

1. Click ‘Get Form’ to open the Molina Healthcare Medicaid, CHIP, & Medicare Prior Authorization Request Form in the editor.
2. Begin by filling out the 'Member Information' section. Enter the date of request, select the plan (Molina Medicaid or Molina Medicare), and provide the member's name and ID number.
3. Specify the service type as either Elective/Routine or Expedited/Urgent. If selecting Expedited/Urgent, ensure you understand its definition related to health deterioration.
4. In the 'Referral/Service Type Requested' section, indicate whether the request is for inpatient, outpatient, surgical procedures, or other services. Include relevant diagnosis codes and CPT/HCPC codes.
5. Complete the 'Provider Information' section by entering details about the requesting provider and facility providing service. Ensure all contact information is accurate.
6. Attach any necessary clinical notes and supporting documentation before submitting your form through our platform for a streamlined process.

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