Medicaid MIChild and Medicare Prior Authorization 2026

1. Click ‘Get Form’ to open the Medicaid MIChild and Medicare Prior Authorization Request Form in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the plan type (Molina Medicaid or Molina Medicare), member name, date of birth, and member ID number. Specify the service type as MIChild or other options.
3. Indicate whether the request is Elective/Routine or Expedited/Urgent. Remember that urgent requests are for situations that could seriously affect health.
4. In the REFERRAL/SERVICE TYPE REQUESTED section, select all applicable services such as Inpatient, Outpatient, Home Health, etc., and provide diagnosis codes along with CPT/HCPC codes.
5. Fill in the number of visits requested and specify the dates of service (DOS) range.
6. Complete the PROVIDER INFORMATION section with details about the requesting provider and facility, including contact information.
7. Finally, ensure to attach any clinical notes or supporting documentation before submitting your form.

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