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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 $1.99 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.

Submission checklist

○Your name, date of birth, member ID

○Your situation described (min 50 chars · 0 entered)

○Insurer fax number

○AI appeal letter generated & reviewed

0 of 4 checks complete

Prior Authorization Request

1. Your Doctor's Information(optional — helps strengthen your appeal)

Doctor Name

NPI (10 digits)

Practice / Clinic Name

Doctor Phone

Doctor Fax

2. Your Information & Insurance

Patient Name *

Date of Birth * (MM/DD/YYYY)

Member ID *

Group Number

3. Clinical Details(optional — include if known)

ICD-10 Code (if known)

Diagnosis (if known)

CPT Code (if known)

Denied Treatment / Procedure

Urgency

4. Your Medical Situation

Describe your situation in your own words *(min 50 chars)0/10000

Explain why you need this treatment, what your doctor has recommended, and what happened when the insurer denied it. The more detail you provide, the stronger your appeal.

5. AI Appeal Letter

Privacy notice: Clicking “Generate with AI” sends your description to OpenAI to draft your appeal letter. Do not include sensitive information beyond what is medically relevant.

6. Submission Method

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