Type Size
* = required field
MI Interpreter Request Form
Health Education Referral Form
Home Health Patient Drive Groupings Model (PDGM) FAQs
Claims Dispute Request Form
Home Care FAQ
Provider Addition Roster
Molina Healthcare of Michigan Provider Contract Request Form
Authorized Representative Designation
Provider Change Form
Prior Authorizations
Q1 2023 PA Matrix including NCH Cardiology Management Program - Effective 3-1-2023
2022 Prior Authorization Matrix - Effective 10/01/2022
2022 Prior Authorization Guide - Effective 10/01/2022
2022 Prior Authorization Matrix - Effective 07/01/2022
2022 Prior Authorization Guide - Effective 07/01/2022
2022 Prior Authorization Guide - Medicare - Effective 07/01/2022
2022 Prior Authorization Guide - Effective 04/01/2022
Prior Authorization/Pre-service Review Guide - Effective 04/01/22
2022 Prior Authorization Matrix - Effective 04/01/2022
2022 Prior Authorization Guide - Effective 01/01/2022
2022 Prior Authorization Guide - Medicare - Effective 01/01/2022
2022 Prior Authorization Matrix - Effective 01/01/2022
Prior Authorization Forms
Pharmacy Prior Authorization Form
MI-Alternative Level of Care Authorization Form
MI-OB Notification Form
Physician Office Laboratory Tests
Provider Change Form Requirements and Guidelines
Provider Request to Change PCP Form
Community Connector Reference Guide
Community Connector Referral Form
CAHPS Provider Brochure
2017 Prior Authorization Guide - effective 04/01/2017
2017 Prior Authorization Matrix - effective 04/01/2017
2017 ADA Attestation Letter
2017 Prior Authorization Matrix eff 01/01/2017
2017 Prior Authorization Guide eff 01/01/2017
Skill Nursing Facility NOMNC Form 2017
2018 Cultural Competency Training Attestation
2018 Prior Authorization Matrix - Effective 10/1/2018
2018 Prior Authorization Guide - effective 10/01/2018
