Frequently Used Forms
Provider Contracting and Credentialing
 Provider Information Update Form |
| Practitioner Enrollment Application |
| Disclosure of Ownership and Control |
| Provider Contract Request Form |
Recoupments and Reimbursements
| Recoupment Form |
Prior Authorizations
MSCAN
|
Prior Authorization LookUp Tool |
|
Prior Authorization Request Form |
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Behavioral Health Prior Authorization Form |
|
Prescription Prior Authorization Form |
CHIP
|
Prior Authorization LookUp Tool |
|
Prior Authorization Request Form (Coming Soon) |
|
Behavioral Health Prior Authorization Form (Coming Soon) |
|
Prescription Prior Authorization Form (Coming Soon) |
Medicaid Prior Authorization Annual Reporting
|
Molina Clinical Services, LLC
Molina Healthcare of Mississippi, Inc.
A list of all health care services, including medications, that are subject to prior authorization can be found on our Prior Authorization Lookup page.
|
Reconsiderations and Appeals
MSCAN
| Claim Reconsideration Request Form |
| Pre-Service Appeal Request Form (Coming Soon) |
CHIP
| Claim Reconsideration Request Form (Coming Soon) |
| Provider Clinical Appeal Request Form (Coming Soon) |
Pregnancy
MSCAN
| Pregnancy Notification Form |
CHIP
| Pregnancy Notification Form (Coming Soon) |
Other Forms and Resources
| Community Connector Referral Form |
| Request to Change Primary Care Provider |
| Weight Watcher Referral Form |
- Provider Contracting and Credentialing
- Recoupments and Reimbursements
- Prior Authorizations
MSCAN
CHIP
- Medicaid Prior Authorization Annual Reporting
Molina Clinical Services, LLC
Prior Authorization Statistics Molina Clinical Services, LLCPercentageThe percentage of STANDARD Prior Authorization requests that were approved, aggregated for all items & services 92% The percentage of STANDARD Prior Authorization requests that were denied, aggregated for all items & services 8% The percentage of Prior Authorization requests that were Approved After an Appeal, aggregated for all items & services 15% The percentage of Prior Authorization requests for which the review timeframe was Extended, and request was Subsequently Approved, aggregated for all items & services 73% The percentage of EXPEDITED Prior Authorization requests that were Approved, aggregated for all items & services 90% The percentage of EXPEDITED Prior Authorization requests that were Denied, aggregated for all items & services 10% Timing Average time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS) 2 Median time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS) 1 Average time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS) 15 Median time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS) 13
Molina Healthcare of Mississippi, Inc.
Prior Authorization Statistics (Medical) Molina Healthcare of Mississippi, Inc.
PercentageThe percentage of STANDARD Prior Authorization requests that were approved, aggregated for all items & services 94.93% The percentage of STANDARD Prior Authorization requests that were denied, aggregated for all items & services 5.07% The percentage of Prior Authorization requests that were Approved After an Appeal, aggregated for all items & services 20.00% The percentage of Prior Authorization requests for which the review timeframe was Extended and request was Subsequently Approved, aggregated for all items & services 80.00% The percentage of EXPEDITED Prior Authorization requests that were Approved, aggregated for all items & services 96.36% The percentage of EXPEDITED Prior Authorization requests that were Denied, aggregated for all items & services 3.62% Days Average time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS) 1.70 Median time that elapsed between submission of STANDARD Prior Authorization and Decision (Measured in DAYS) 1.29 Hours Average time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS) 20.88 Median time that elapsed between submission of EXPEDITED Prior Authorization and Decision (Measured in HOURS) 18.11
A list of all health care services, including medications, that are subject to prior authorization can be found on our Prior Authorization Lookup page.
- Reconsiderations and Appeals
- Pregnancy
- Other Forms and Resources
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