Frequently Used Forms

 

Appeals

 Grievance Consent Form
 Provider Appeal Form

 

Behavioral Health

 Behavioral Health Prior Authorization Form
 Combined MCE Behavioral Health Provider Primary Care Provider Communication Form

 

Contracting & Provider Network

 Provider Contract Request Form

 Wisconsin W9

 Provider Information Update Form

 LTSS Provider Change of Ownership Notification Form

 Get to Know Your Molina LTSS Contracting Team

 

Credentialing

 Molina Healthcare of WI- Practitioner Application

 Molina Healthcare of WI CAQH Credentialing Checklist

 My Choice Wisconsin Attestation Form

 LTSS Credentiaing 101

 LTSS Credentialing FAQ

 

Claims and Adjustments

 Overpayment Form
 

Prior Authorization

 Q2 2026 PA Code Updates

 2026 PA Guide Request Form

 Q1 2026 PA Code Updates

 Q4 2025 PA Code Updates

 Q3 2025 PA Code Updates 

 Evolent 2025 Codification List for Oncology/Radiology and Cardiology Prior Authorizations

 Q2 2025 Medicaid Prior Authorization Code Updates

 Q1 2025 Prior Authorization Guide

 Q1 2025 Medicaid Prior Authorization Code Updates

 Q4 2024 PA Code Updates

 Q3 2024 PA Code Updates

 Q2 2024 PA Code Updates

 Q1 2024 PA Code Updates

 2024 Medicaid PA Guide Request Form 

 

Referral and Other Health Care Forms

 Peer to Peer and Provider Reconsideration Form
 Hospice Benefit Election Form
 National Diabetes Prevention Program Referral
 Authorization for Use and Disclosure of PHI
 Authorization for Use and Disclosure of PHI (Spanish)
 PNCC Provider Notification Form
 Case Management Referral Form
 Clinical Care Coordination Referral Form
 Pregnancy Notification Form

 

CMS-0057 Prior Authorization Annual Reporting

  2025 Prior Authorization Guide

  Prior Authorization Lookup Tool

Medicaid SSI Prior Authorization Annual 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. 93%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 7%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 57%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 100%
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. 92%
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. 78%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 92%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 8%
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) 6
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) 4
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) 29
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) 23

 

Medicaid BadgerCare Plus Prior Authorization Annual 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. 90%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 10%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 63%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 67%
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. 80%
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. 89%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 91%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 9%
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) 5
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) 4
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) 25
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) 22