Get Molina Of Washington Prior Authorization Form 2020-2025

This guide provides clear and comprehensive instructions on how to fill out the Molina of Washington Prior Authorization Form online. By following these steps, you will ensure that you complete the form accurately and efficiently.

Follow the steps to complete your prior authorization request

1. Click ‘Get Form’ button to obtain the form and open it in your selected editor.
2. Begin by entering the member information in the designated fields. Include the plan type (Molina Medicaid or Molina Medicare), as well as the member's name, member ID number, service type, and date of birth.
3. Indicate the phone number of the member and specify if the request is expedited or urgent. Be sure to understand the definition of urgent service requests, which is when treatment requested is needed to prevent serious deterioration in health.
4. Select the type of referral or service being requested. Options may include inpatient services, outpatient surgical procedures, speech therapy, diagnostic procedures, and other categories as specified.
5. Input the ICD-10 diagnosis code along with a brief description of the condition. Ensure accuracy as this information is vital for the authorization process.
6. Specify the CPT/HCPC code and description for the procedures being requested. Additionally, indicate the number of visits requested for service.
7. Provide the date of service (DOS), including the start and end dates. Additionally, mention that clinical notes and any supporting documentation should be attached along with the form.
8. Fill out the provider information including the requesting provider's name, the facility providing the service, the contact person's name at the requesting provider’s office, and their phone and fax numbers.
9. After all sections are filled out correctly, review the form for completeness and accuracy. Ensure that all required fields have been addressed.
10. Save changes to your form, then download, print, or share it as needed to complete your submission of the prior authorization request.

Get started on your Molina of Washington Prior Authorization Form online today.