[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286781-105":53,"doc-detail-286781-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","molina-healthcare-of-michigan-prior-authorization-request-form","Molina Healthcare of Michigan - Prior Authorization Request Form","","This document serves as the official Prior Authorization Request Form for Molina Healthcare of Michigan members. It provides a standardized framework for healthcare providers to submit requests for various medical services, including inpatient and outpatient surgeries, diagnostic procedures, rehabilitation, and durable medical equipment. The form collects essential patient demographics, diagnostic and procedural codes, and requesting provider details to facilitate insurance coverage review. It clearly outlines contact information for Medicaid and Medicare requests, defines the criteria for expedited or urgent processing to ensure critical patient care is prioritized, and mandates the submission of supporting clinical documentation to support medical necessity reviews.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/molina-healthcare-of-michigan-prior-authorization-request-form/286781/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/molina-healthcare-of-michigan-prior-authorization-request-form/286781.png","ImageObject",442,249,{"name":88,"@type":89},"Kurz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-25","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the criteria for submitting an urgent or expedited request?","Question",{"text":108,"@type":109},"An urgent or expedited request is defined as a situation where the requested treatment is necessary to prevent serious deterioration in a member's health or could jeopardize the member's ability to regain maximum function.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What documentation must accompany the request form?",{"text":113,"@type":109},"Providers are required to submit clinical notes and any relevant supporting documentation alongside the completed request form to facilitate the authorization process.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should providers send Medicaid and Medicare prior authorization requests?",{"text":117,"@type":109},"Medicaid requests should be faxed to (800) 594-7404, while Medicare requests should be directed to (888) 295-7665.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},286781,1790110531,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},2336478945635,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Molina Healthcare of Michigan Prior Authorization Request Form  \nPhone Number: (888) 898-7969  \nMedicaid Fax Number: (800) 594-7404  \nMedicare Fax: (888) 295-7665  \nMember I nformation  \nPlan:  Molina Medicaid  Molina MI Child  Molina Medicare  Other:    \nMember Name:   DOB:    \nMember ID\\# :   Member Phone \\# :  ( )   \nService I s:  Elective/ Routine  Expedited/ Urgent *  \n* Definition of Urgent / Expedited service request designation is when the treatment requested is required to prevent serious deterioration in the member’s health or could jeopardize the member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/ non-urgent.  \n\n| Referral/ Service Type Requested |  |  |\n| --- | --- | --- |\n| I npatient\u003Cbr> Surgical Procedures  ED Admission\u003Cbr> Direct Admission  SNF\u003Cbr> Rehab\u003Cbr> LTAC | Outpatient\u003Cbr> Surgical Procedure  Rehab (PT, OT, & ST)  Diagnostic Procedure  Imaging\u003Cbr> Chiropractic  Wound Care  Infusion Therapy |  DME |\n|  |  |  Home Health |\n|  |  |  I n Office |\n\nReferred To Provider/ Facility Name & Tax I D\\# :    Referred To Address & Phone\\# :    \nDiagnosis Code & Description:    \nCPT/ HCPCS Code & Description:    \nNumber of visits requested:   Date(s) of Service:    \nPlease send clinical notes and any supporting documentation  \nProvider I nformation  \nRequesting Provider Name and Address:    \nContact @ Requesting Provider’s:    \nPhone Number:  ( )  Fax Number:  ( )   \nFor Molina Use Only:  \n2013 MI Molina Healthcare/ Molina Medicare PA GUI DE 5/ 8/ 13","cbCainX8iEttTtMQ","https://ap.wps.com/l/cbCainX8iEttTtMQ","pdf",59243,"English","## Member Information\n## Service Type Requested\n## Referred To Provider/Facility Details\n## Clinical Diagnosis and Procedure Information\n## Requesting Provider Contact Information","[{\"question\":\"What is the criteria for submitting an urgent or expedited request?\",\"answer\":\"An urgent or expedited request is defined as a situation where the requested treatment is necessary to prevent serious deterioration in a member's health or could jeopardize the member's ability to regain maximum function.\"},{\"question\":\"What documentation must accompany the request form?\",\"answer\":\"Providers are required to submit clinical notes and any relevant supporting documentation alongside the completed request form to facilitate the authorization process.\"},{\"question\":\"Where should providers send Medicaid and Medicare prior authorization requests?\",\"answer\":\"Medicaid requests should be faxed to (800) 594-7404, while Medicare requests should be directed to (888) 295-7665.\"}]","Molina Healthcare of Michigan - Prior Authorization Request Form | PDF",1789631540]