Prior authorization to Molina Healthcare

Molina Healthcare operates state Medicaid and Marketplace plans across multiple states, but there is no single national PA fax number. Each state subsidiary maintains its own submission fax number, required forms, and clinical review criteria. Call Molina Provider Services for your specific state before submitting to get the correct fax number — a PA faxed to the wrong state office will not be processed and may not be acknowledged.

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Molina Healthcare

MedicaidMarketplace

PA Fax: Enter manually
PA Phone: +18887569417
Standard turnaround: 5 business days
Urgent turnaround: 72 hours

Fax number varies by state plan. Call Molina Provider Services for your state-specific fax number.

Molina Healthcare provider portal →

What you'll need

PhoneFaxPortal

☐Identify your state Molina plan — fax number and requirements differ by state
☐Call Provider Services to get state-specific fax number before submitting
☐Patient member ID
☐ICD-10 diagnosis code(s)
☐CPT procedure code(s)
☐Clinical notes and prior treatment history
☐Ordering provider NPI

▶Common denial reasons

⚠State-specific Medicaid criteria not met
⚠Prior treatment history not documented (step therapy required)
⚠Service not on state Medicaid fee schedule
⚠Missing state-specific required documentation

Verified 2026-05-20. Check payer site for current rules →

From $2.99 per submission

PA Agent requires an account so you can track submissions, record outcomes (approved/denied), and pre-fill appeals automatically. It's free to join.

You can preview the form below — sign in before generating or submitting.

⬆ Import from CSVDownload template

Submission checklist

○Provider name, NPI, practice name

○Provider phone & fax number

○Patient name, DOB, member ID

○ICD-10, diagnosis, CPT, procedure

○Clinical notes (min 50 chars · 0 entered)

○Fax destination number

○AI justification generated & reviewed

0 of 7 checks complete

Prior Authorization Request

1. Provider Information

Provider Name *

NPI * (10 digits)

Practice Name *

Provider Phone *

Provider Fax *

2. Patient & Insurance

Patient Name *

Date of Birth * (MM/DD/YYYY)

Member ID *

Group Number

💬 Patient notifications: add the patient's email below and they'll automatically receive an email when you record the insurer's decision on the tracking page — no phone call needed.

Patient Email (for outcome notifications)

Patient Phone (for future SMS notifications)

3. Clinical Details

ICD-10 Code *

Diagnosis Description *

CPT Code * (5 digits)

Procedure Description *

Urgency

4. Clinical Notes

Provider notes & supporting rationale *(min 50 chars)0/10000

5. AI Clinical Justification

PHI notice: Clicking “Generate with AI” sends clinical notes and diagnosis to OpenAI for processing. Do not include information beyond what is clinically necessary. Review your organization's policies before submitting patient data to third-party AI services.

6. Submission Method

Fax number varies by state plan. Call Molina Provider Services for your state-specific fax number. Find fax number →