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Forms and Documents
When can you Enroll?
2023 Marketplace Provider Handbook
2022 Marketplace Provider Handbook
2021 Marketplace Provider Handbook
Prior Authorization LookUp Tool
Provider Authorization Guide/Service Request Form (Effective: 7/1/2023)
2020 Codification Document (Effective 07/01/20)
Web Portal QRG
2020 Provider Quick Reference Guide
In-Office Tests List - Eff: 03/01/2020
2020 Codification Document (Effective 4/1/2020))
2019 Codification Document (Effective 10/15/19)
Provider Appeal/Dispute Form
Molina In-Network Referral Form
Provider Contract Request Form
MFL 8 Prescription Limit Form
Child Health Check Up Billing and Referral Codes
Pharmacy Prior Authorization/Exception Form - (Effective: 01/01/18)
Pregnancy Notification Form
No Surprises Act - Independent Dispute Resolution Form (Non-Contracted Providers only)
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