Get Molina Centennial Prior Authorization Form

Filling out the Molina Centennial Prior Authorization Form online can be a straightforward process if you follow the correct steps. This guide provides clear instructions on how to accurately complete each section to ensure your request is processed efficiently.

Follow the steps to complete the Molina Centennial Prior Authorization Form online.

1. Press the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Fill out the request date at the top of the form to indicate when the request is being made.
3. Provide the member information by entering the member's name, ID number, date of birth, any other insurance carrier and their policy/ID number, and a valid phone number.
4. Input your provider information, including the requesting provider's name, phone number, and fax number. Include the servicing provider or facility details, including their address, tax ID or NPI number.
5. Select whether this is a new or initial request or ongoing care. If applicable, provide the previous authorization number.
6. Specify the type of request being made, such as DME/prosthetic/orthotic or inpatient stay, as well as the length of stay information and facility details.
7. Complete the diagnosis section by entering the relevant ICD-9 codes, ensuring that this information is clearly indicated.
8. List the procedures that match the appropriate CPT codes required for the request.
9. Indicate the requested effective date and end date for the services, along with the number of visits or units needed.
10. Make sure to attach any necessary supporting clinical documentation, including symptoms, past medical history, and details of previous treatments, as these are critical for processing. Review all entries for accuracy.
11. Once you have filled out and reviewed the form, save your changes, and then download, print, or share the form as needed.

Start completing your documents online today to ensure efficient processing!