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Molina service request form

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The document outlines the process for requesting prior authorizations for Medi-Cal, Healthy Families, and Medicare services. It includes contact information for submitting requests, guidelines for urgent and non-urgent service requests, and a service request form that captures patient details, requested services, provider information, and clinical indications. Additionally, it emphasizes confidentiality and the importance of member eligibility for claims payment.

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Click ‘Get Form’ to open the Molina Service Request Form in the editor.
Begin by entering the Tracking Number and Expiration Date at the top of the form. This information is crucial for processing your request.
Select the appropriate product from the options: Medi-Cal, Healthy Families, or Medicare. Indicate whether the service is Non-Urgent or Urgent, providing a brief explanation if urgent.
Fill in the Member's Name, Date of Birth, and Member ID (Social Security Number). Ensure accuracy as this information verifies eligibility.
Complete the Address and Phone Number fields for both the member and requesting provider. This ensures proper communication regarding your request.
Specify the Referral/Service Type Requested and provide details such as Requested Length of Stay (LOS) or Surgical Procedure specifics.
In the Clinical indications section, include relevant medical history and attach any necessary documents to support your request.
Finally, ensure that both requesting and referring provider signatures are included before submitting your form for review.

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2012	4.8 Satisfied (307 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What type of insurance is Molina Healthcare of California?

Molina Healthcare of California has been providing government-funded care for over 40 years. The company serves members through Medi-Cal, Medicare, Medicare-Medicaid (Duals), and Covered California (Marketplace).

How do I contact Molina CA?

You may also call Molina Telesales at (855) 542-1974 or Covered California at (800) 300-1506.

Is Molina Healthcare of IL Medicaid?

Molina Healthcare of Illinois provides Medicaid (HealthChoice), MMAI (MMP/Duals), and MLTSS services to all 102 Illinois counties.

Is Molina Healthcare Texas Medicaid?

Molina has a large group of specialists, therapists, clinics, and hospitals that can provide you with Medicaid services. Available in Dallas, El Paso, Harris, Hidalgo and Jefferson Service Areas.

What is Illinois state Medicaid called?

In 1999, we were incorporated in California as the parent company of our health plan subsidiaries under the name American Family Care, Inc. In March 2000, we changed our name to Molina Healthcare, Inc.

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Are Medicaid and Molina the same thing?

Molina Healthcare, Inc. is a managed care company headquartered in Long Beach, California, United States. The company provides health insurance to individuals through government programs such as Medicaid and Medicare.