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Effective Jan. 1, 2026, Molina Healthcare of Ohio, Inc. will discontinue fax submissions of prior authorizations (PA). All requests for PA must be submitted through the Availity Essentials portal.

If you have questions, contact Provider Relations at OHProviderRelations@MolinaHealthcare.com.

Claims

Claim Reconsideration Request Form (Non-Clinical Claim Dispute)

Dental Request for Claim Reconsideration – Please review the Dental Provider Manual

Return of Overpayment

In-Office Laboratory Test List

Prior Authorizations

Nursing Facility Request Form

Synagis (RSV) Authorization

Behavioral Health Respite Services PA Reference Guide

Medicaid Authorization Form – Community Behavioral Health

Prior Authorization Code Changes

Medicare and MyCare: Q2 2026 PA Code Changes

Marketplace: Q2 2026 PA Code Changes

Medicaid: Q2 2026 PA Code Changes Effective April 1 – April 5

Medicaid: Q2 2026 PA Code Changes Effective April 6

Medicare and MyCare: Q1 2026 PA Code Changes

Marketplace: Q1 2026 PA Code Changes

Medicaid: Q1 2026 PA Code Changes

Archived PA Code Lists and Changes

Prior Authorization Reconsiderations and Appeals

Authorization Reconsideration Form (Authorization Appeal or Clinical Claim Dispute Form)

Grievance/Appeal Request Form

Did you know a PA Denial Reconsideration is faster than an appeal in most cases?

Provider Contract Templates

Molina Healthcare Dental Provider Services Agreement

Molina Healthcare Hospital Services Agreement

Molina Healthcare Provider Services Agreement

Abortion, Hysterectomy and Sterilization

ODM Consent to Sterilization Form

Guidelines for Completing Consent to Sterilization Form

ODM Consent to Hysterectomy Form

ODM Abortion Certification Form

Other Forms and Resources

Critical Incident Referral Template (Medicaid Only)

Ohio Urine Drug Screen Prior Authorization (PA) Request Form

PRAF 2.0 and other Pregnancy-Related Forms

ODM Health Insurance Fact Request Form

Non-Contracted Practice/Group Information

Ohio Dental Provider Contract Request Form
Ohio Provider Contract Request Form*
ODM Designated Provider and Non-Contracted Provider Guidelines
Ohio Provider Contracting Guide
*For first-time providers wanting to contract with Molina Healthcare of Ohio (MHO), or for existing MHO providers wanting to add a new product to their contract.

Contracted Practices/Groups Making Changes

Provider Information Form*

CAQH Provider Data Form

Request to Change Provider Form

Ownership and Control Disclosure Form

*Add/change/term information for contracted providers/groups.