E email the completed form to MHONon-ParContractRequests@MolinaHealthcare.com or fax to the attention of Provider Contracts at (866) 384-1226. If you are joining a contracted group, please do not complete or submit this form. On the Molina Healthcare website, look to the “Contracted Providers Making Changes” section for the appropriate forms and instructions. Provider Name: Provider Type/Specialty: Medicaid ID Number: Practice Name: *(.
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How to fill out the OH MHO-0443 online
Filling out the OH MHO-0443 form is an essential step for providers seeking to join Molina Healthcare of Ohio's network. This guide will help you navigate each section of the form, ensuring a smooth online submission process.
Follow the steps to successfully complete the OH MHO-0443 form.
- Press the ‘Get Form’ button to access the OH MHO-0443 form and open it in the editor.
- Complete the 'Provider Name' field by entering the full name of the provider applying for contract.
- Fill in the 'Provider Type/Specialty' section, specifying the relevant specialty of the practice.
- Enter the 'Medicaid ID Number' that corresponds to the provider.
- Input the 'Practice Name' under which the provider operates.
- If applicable, list the names and specialties of all practitioners in the group if this is a group practice. You may attach a separate sheet if needed.
- Fill out the 'Mailing Address' and, if different, 'Primary Office Location'.
- Identify the 'County' where the practice is located.
- Provide the name of the 'Person Completing This Form'.
- Enter a contact 'Phone' number and the 'Provider TIN' for the practice.
- Fill in the 'Email Address' to receive any communications regarding your application.
- Indicate whether all practitioners are employed physicians of the group by selecting 'Yes' or 'No'. If 'No', be sure to follow up on the additional requirements.
- Include any additional information relevant to your practice in the provided section.
- Once all fields are completed, review the form for accuracy. You may then save changes, download, print, or share the form as necessary.
Complete your documents online to ensure a prompt response from Molina Healthcare of Ohio.
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What is the phone number for Molina Healthcare of Ohio provider enrollment?
Provider Services – (855) 322-4079 8 a.m. to 5 p.m., Monday to Friday (MyCare Ohio available until 6 p.m.)
How do I become a Molina provider in Ohio?
If you are not currently a contracted provider with Molina Healthcare of Ohio and you are interested in joining our network of quality health care providers, or if you wish to add a line of business to your existing contract, please email this completed form to OHContractRequests@MolinaHealthcare.com or fax to the ...
Who is eligible for Molina Ohio?
Be a citizen of the United States or a legally admitted alien. Have a DON score of 29 points or more. Have less than $17,500 in assets or $35,000 family assets for a child under the age of 18. Needs will be met at a cost less than or equal to the cost of nursing services in an institutional setting.
Is Molina Healthcare of Ohio a Medicaid plan?
Our Molina Healthcare of Ohio Medicaid Health Plan provides quality, no-cost health care for you and your family. Learn more about your health plan, what's covered and the many programs we offer.
What is the payer ID for Molina Healthcare of Ohio?
Medicare, MyCare Ohio, and Marketplace: Providers may submit claims, PA, eligibility inquiries, claim status inquiries, and associated attachments via an EDI clearinghouse using Payer ID 20149.
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