Frequently Used Forms

To access additional forms, including the latest copy of the Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section: STATE OF SOUTH CAROLINA

To access additional forms, including the latest copy of the Consent for Sterilization Form, please visit the SCDHHS Provider Manual Forms section: https://www.scdhhs.gov/internet/pdf/manuals /Physicians/Forms.pdf

Healthcare Services Forms: 

Health Education Referral Form

Disease Management/Case Management Referral Form

Delivery Notification Form

Neonatal Transfer Form

Pregnancy Notification Report

Abortion Statement  ***

SBIRT Integrated Screening Tool

 

Prior Authorization Forms: 

Universal Prior Authorization Form BabyNet

MCO Universal Prior Authorization Newborn Form

BH Prior Authorization-Outpatient Treatment-Higher Level of Care Form

Prior Authorization Request Form

Prior Authorization Medications Form

Advanced Imaging Prior Auth Guide

Sunset of Legacy Authorization Notice


Provider Network/Credentialing Forms: 

Credentialing Packet and Uniform Application

Practice Demographics Form

Provider Change Form

Primary Care Provider Change Request Form

Contract Request Form

Facility HDO Form

SCDHHS Ownership Form  ***

Non Medicaid Enrolled Ownership Disclosure Form

 

Claims Forms and Documents: 

Provider Recovery Reversal Permission Form

Claims Workflow Infographic

 

CMS-0057 Prior Authorization Annual Reporting

download arrow button  2025 Prior Authorization Guide

download arrow button  Prior Authorization Lookup Tool

 

South Carolina Medicaid Prior Authorization Report 2025


Prior Authorization Statistics
Molina Healthcare Inc
Percentage
The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 73%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 27%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 18%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 16%
The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 58%
The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 50%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 89%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 11%
Timing
Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 8
Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 9
Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 21
Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 20

*** Data published by March 31, 2026, covering calendar year 2025.

*** SCDHHS STATE MANDATED REQUIRED FORMS FOR SUBMISSION