Molina Prior Authorization Template 2026: Request, Peer-to-Peer & Denial Appeal Letters

Why a Molina PA Denial Is a Medicaid Problem First

Most Molina prior authorization denials are Medicaid managed-care decisions, so federal Medicaid rules — not a commercial-plan provider manual — set the floor for decision deadlines, appeal rights, and escalation. That changes who files the appeal, how long you have, and where it goes next.

Three differences matter for a billing team used to commercial PA:

• The appeal belongs to the member. Under 42 CFR 438.402(c), a provider may request a Medicaid plan appeal "if State law permits and with the written consent of the enrollee." Without the consent form, a provider-signed appeal of a pre-service denial may be treated as a provider dispute or returned.
• There is only one level of plan appeal. The same regulation limits each Medicaid managed care plan to one level of enrollee appeal. After that, the next step is the state's fair hearing — not a second internal review.
• Decision deadlines and filing rights are different. States can require Molina to decide an authorization or appeal faster than the federal maximum. That does not shorten the member's federal 60-calendar-day plan-appeal filing period. Peer-to-peer windows and fair-hearing deadlines must be checked separately for the state and product.

Molina also runs Medicare Advantage and, in some states, Marketplace plans. Those follow different rules, covered in their own sections below. Applicable integrated Medicare-Medicaid plans are an exception: their integrated authorization and appeal procedures use 42 CFR 422.629–422.634; confirm the integrated route in the denial notice before using either template. If you are disputing a paid or denied claim rather than a pre-service authorization, use the Molina appeal letter template and the Molina appeal form guide instead.

How to Submit a Molina Prior Authorization in 2026

Check whether the service needs authorization with your state's Molina PA Lookup Tool, then submit the medical request in Availity Essentials with a clinical summary attached. Fax is no longer a reliable fallback.

Molina's state provider pages now say this directly. The Ohio PA page states that effective 1/1/2026, providers must submit medical benefit PA requests through Availity "as Molina no longer accepts fax submissions." The Michigan PA page carries the same instruction starting 2/1/26. Both pages tell providers to keep pharmacy PA on its separate process and not to submit pharmacy requests through Availity.

How long Molina has to decide

For ordinary Medicaid managed care, 42 CFR 438.210(d) caps standard authorization decisions at 7 calendar days for contract rating periods starting on or after January 1, 2026 (it was 14 days before that). Expedited decisions are due within 72 hours when the provider indicates, or the plan determines, that the standard timeframe could seriously jeopardize the member's life, health, or ability to attain, maintain, or regain maximum function. A standard decision can be extended by up to 14 calendar days if the member or provider requests it, or the plan justifies needing additional information and explains how the extension is in the member's interest. For an expedited decision, an extension requires the member's request or that same plan justification; a provider's request alone is not the extension criterion.

These are federal maximums. Your state may require faster decisions — check the Molina provider manual for your state.

Molina Prior Authorization Clinical Summary Template

Attach this summary to the Availity request so the reviewer sees the clinical case in one page instead of piecing it together from chart notes. Its job is to line your documentation up against the criteria Molina will apply, before the first review — the cheapest point to prevent a denial.

MOLINA HEALTHCARE — PRIOR AUTHORIZATION CLINICAL SUMMARY
(Attach to Availity Essentials authorization request)

Date: [MM/DD/YYYY]
Molina Plan: Molina Healthcare of [State] — [Medicaid / Medicare Advantage / Marketplace]
Availity Reference #: [If already created]
Request Type: [Standard / Expedited — if expedited, see Urgency section]

--- MEMBER ---
Name: [Last, First]
DOB: [MM/DD/YYYY]
Molina Member ID: [ID from card]

--- REQUESTING / RENDERING PROVIDER ---
Ordering Provider: [Name, credentials, NPI]
Rendering Provider / Facility: [Name, NPI, address]
Contact for Clinical Questions / Peer-to-Peer: [Name, direct phone, best hours]

--- SERVICE REQUESTED ---
CPT/HCPCS: [Code(s) + description]
Units / Visits / Days: [Number]
ICD-10: [Primary] [Secondary]
Place of Service: [Office / Outpatient / Inpatient / Home]
Requested Dates: [Start – end]

--- CRITERIA BEING MET ---
Molina Clinical Policy / Criteria Applied: [Policy name or number from the state's Molina clinical policy page, or the criteria set named in a prior denial]
Criterion 1: [Quote or paraphrase the criterion] → Met by: [specific finding, date, source document]
Criterion 2: [Criterion] → Met by: [finding, date, source]
Criterion 3: [Criterion] → Met by: [finding, date, source]

--- CLINICAL HISTORY (brief) ---
Diagnosis and onset: [Condition, date of onset or diagnosis]
Current functional status: [Objective measures — scores, ROM, labs, imaging]
Prior treatment tried and outcome:
- [Treatment 1], [dates], [result / reason stopped]
- [Treatment 2], [dates], [result / reason stopped]
Why this service, why now: [1–3 sentences tying findings to the request]

--- URGENCY (complete only if requesting expedited review) ---
Applying the standard timeframe could seriously jeopardize the member's
[life / physical or mental health / ability to attain, maintain, or regain
maximum function] because: [specific clinical reason].

--- ATTACHMENTS ---
[ ] Most recent office note(s) supporting the request
[ ] Imaging / lab / test results cited above
[ ] Records of prior treatment and outcomes
[ ] Specialist consult note (if applicable)
[ ] Letter of medical necessity (if required by the criteria)

Prepared by: [Name, title]   Phone: [Direct line]

What to Do When Molina Denies a Prior Authorization

Read the denial notice first, then pick the route that fits the reason. Federal rules require the notice to explain the reasons, the member's right to free copies of relevant records, appeal rights including expedited review, and the right to continued benefits (42 CFR 438.404).

Peer-to-peer review

A peer-to-peer lets the ordering physician discuss the case with a Molina Medical Director. Confirm whether it is available and use the number and deadline printed on the denial notice or in the current Molina provider manual for that state and product. Do not transfer a Marketplace deadline to Medicaid or assume another state's window applies.

A peer-to-peer does not stop the 60-day appeal clock. Prepare with our peer-to-peer review call script, and see how peer-to-peer reviews work for what reviewers typically need.

Medicaid plan appeal deadlines

Sources: 438.402, 438.408, 438.420. States can require faster plan decisions; they cannot shorten the 60-day member filing right under these rules. Check the notice for the state's fair-hearing window. Continuation also requires previously authorized services ordered by an authorized provider and an unexpired authorization. The member or a permitted representative must request continuation; providers cannot request it on the member's behalf. If the final decision is adverse, costs may be recovered under the state's policy and plan contract.

Molina Medicaid PA Denial Appeal Letter Template

Use this for an ordinary Molina Medicaid plan appeal when the member consents to you appealing on their behalf and state law permits. It includes an optional expedited request and a separate member-signed continuation request for eligible reductions or terminations of an existing authorization. Confirm the state's representative and submission requirements; a provider signature cannot substitute for the member's continuation request.

[PRACTICE LETTERHEAD]

[Date]

Molina Healthcare of [State] — Appeals
[Address, fax, or portal from the denial notice — use exactly what the notice lists]

RE: Request for [Standard / EXPEDITED] Appeal of Prior Authorization Denial
Member: [Name]   DOB: [MM/DD/YYYY]   Molina Member ID: [ID]
Authorization / Reference #: [Number]
Date of Denial Notice: [MM/DD/YYYY]
Service: [CPT/HCPCS + description], [units], [requested dates]
Ordering Provider: [Name, NPI]

To the Molina Appeals Unit:

On behalf of [Member Name], and with the member's written consent
(enclosed), I request an appeal of Molina's [date] decision denying prior
authorization for [service]. This appeal is filed within 60 calendar days
of the denial notice under 42 CFR 438.402(c)(2)(ii).

DENIAL REASON
The notice states: "[Quote the denial reason verbatim]."
Criteria cited: [Molina clinical policy or criteria named in the notice].

WHY THE SERVICE MEETS THE CRITERIA
1. [Criterion]: [Member's specific finding, with date and source record].
2. [Criterion]: [Finding, date, source].
3. [Criterion]: [Finding, date, source].
[If the denial cited missing information:] The enclosed [records] were not
included with the original request and directly address [the gap].

Prior treatment: [Treatment], [dates], [outcome]. [Treatment], [dates],
[outcome]. [Explain why further conservative care is not appropriate.]

[OPTIONAL — EXPEDITED REVIEW]
I am requesting expedited resolution. Taking the time for a standard
resolution could seriously jeopardize the member's [life / physical or
mental health / ability to attain, maintain, or regain maximum function]
because [specific clinical reason], consistent with 42 CFR 438.410.

[OPTIONAL — SEPARATE MEMBER REQUEST FOR CONTINUATION OF BENEFITS]
[For reduction, suspension, or termination of previously authorized
services ordered by an authorized provider, with an unexpired
authorization. Have the member or permitted representative sign and
submit this request through the plan's required route; the provider
cannot request continuation on the member's behalf.]
I, [Member Name / permitted representative], request continued benefits
for [service] pending the appeal under 42 CFR 438.420. The original
authorization ends [date]. This request is filed on or before the later
of 10 calendar days after the plan sent the notice on [date] or the
intended effective date of [date]. I understand costs may be recovered
if the final decision is adverse, consistent with state policy and the
plan contract.
Member / permitted representative signature: __________ Date: ______
[Representative name, relationship and authority, if applicable]

REQUESTED ACTION
Please reverse the denial and authorize [service, units, dates]. I also
request, on the member's behalf and free of charge, copies of the case file
and the criteria used in this decision. I am available for discussion with
the reviewing Medical Director at [direct phone].

Sincerely,

[Name, credentials]
[NPI] | [Practice] | [Phone] | [Fax]

Enclosures:
[ ] Member written consent / authorized representative form
[ ] Copy of the denial notice
[ ] Clinical summary and supporting records
[ ] Letter of medical necessity
[ ] Peer-to-peer notes (if one was held)

---------------------------------------------------------------
MEMBER CONSENT (use Molina's state form if one is required)
I, [Member Name], Molina Member ID [ID], authorize [Provider Name, NPI]
to file an appeal on my behalf of Molina's decision dated [date] regarding
[service], and to receive information about this appeal.

Member signature: ____________________   Date: __________
[If signed by a parent/guardian/legal representative: name and relationship]

Molina Medicare Advantage Pre-Service Reconsideration Template

Ordinary Molina Medicare Advantage PA denials follow Medicare Part C rules, with independent review rather than the Medicaid fair-hearing route. Applicable integrated Medicare-Medicaid plans use their integrated process; follow that plan's notice. The treating physician can request a standard pre-service reconsideration on the member's behalf after notifying the member (42 CFR 422.578(c)) — no appointment-of-representative form needed for that standard request. Expedited requests use 42 CFR 422.584.

The request is due within 60 calendar days after receipt of the denial notice, and receipt is presumed to be 5 days after the notice is issued (42 CFR 422.582). Molina must decide a standard pre-service reconsideration within 30 calendar days and an expedited one within 72 hours. If Molina upholds the denial, it must forward the case to the independent review entity automatically (42 CFR 422.590).

[PRACTICE LETTERHEAD]

[Date]

Molina Healthcare — Medicare Appeals and Grievances
[Address / fax from the denial notice]

RE: Request for [Standard / EXPEDITED] Pre-Service Reconsideration
Member: [Name]   DOB: [MM/DD/YYYY]   Molina Medicare ID: [ID]
Organization Determination / Reference #: [Number]
Date of Denial Notice: [MM/DD/YYYY]
Service: [CPT/HCPCS + description], [requested dates]

To Molina Medicare Appeals:

As the physician treating [Member Name], I request reconsideration of
Molina's [date] organization determination denying [service].
[STANDARD: I have notified the member of this request under
42 CFR 422.578(c). This request is filed within 60 days of receipt of
the denial notice under 42 CFR 422.582.]
[EXPEDITED: I request expedited reconsideration under 42 CFR 422.584;
the clinical urgency is described below.]

DENIAL REASON
"[Quote the denial reason verbatim]."

COVERAGE BASIS
[Cite the Medicare coverage rule that applies: NCD / LCD number and title,
or the Molina MA coverage criteria named in the notice.]

CLINICAL SUPPORT
1. [Coverage criterion]: [Finding, date, source record].
2. [Coverage criterion]: [Finding, date, source record].
3. Prior treatment: [Treatment, dates, outcome].

[OPTIONAL — EXPEDITED]
Applying the standard timeframe could seriously jeopardize the member's
life, health, or ability to regain maximum function because [specific
reason]. I request a decision within 72 hours.

Please reverse the determination and approve [service]. If the denial is
upheld, please forward the case file to the independent review entity as
required by 42 CFR 422.590.

Sincerely,

[Name, credentials] | [NPI] | [Phone] | [Fax]

Enclosures: denial notice; clinical summary; supporting records;
letter of medical necessity.

For the claim-side Molina MA appeal route and the IRE → ALJ escalation ladder, see the Molina appeal guide.

Molina Marketplace Plans

Molina Marketplace (individual and family) PA denials are neither Medicaid nor Medicare decisions. They follow ACA internal appeal and external review rules, so use the appeal instructions and deadline in the Marketplace denial notice. Do not use the Medicaid consent letter or the fair-hearing route for these members. Ohio's Molina PA page lists Marketplace separately from Medicaid for this reason.

Common Molina PA Mistakes

Most avoidable Molina PA delays come from routing and paperwork, not clinical disagreement:

• Faxing a medical PA in a digital-only state. Ohio and Michigan no longer accept it in 2026. Check your state's PA page before relying on fax anywhere.
• Sending pharmacy PA through Availity. Both Molina pages tell providers to keep pharmacy on its separate process. In Ohio Medicaid, pharmacy PA goes to Gainwell.
• Appealing without member consent. For Medicaid pre-service denials, the provider files on the member's behalf. Missing consent can turn an appeal into a rejected submission.
• Missing the peer-to-peer window. It is measured in business days in some states — and it is not an appeal.
• Using the Medicaid letter for a Medicare Advantage member (or the reverse). The rules, deadlines, and escalation paths differ.
• Skipping continuation of benefits. For eligible reduced or terminated existing services, help the member or permitted representative request continuation by the later of 10 calendar days after the notice is sent or the intended effective date. Providers cannot make that request on the member's behalf.

For a payer-neutral view of the whole process, see the complete prior authorization denial guide and what happens after a PA denial. If the fair hearing is next, use the Medicaid fair hearing guide.

How Muni Appeals Helps With Molina PA Denials

Molina PA appeals are mostly assembly work: matching the denial reason to the criteria, pulling the right records, choosing the Medicaid, Medicare Advantage, or Marketplace route, and getting the consent and deadlines right. Muni Appeals organizes the denial notice and records you upload into a draft appeal packet for your staff to review, with the denial reason, criteria, and supporting evidence lined up. Your team confirms the route for the member's state and product and submits it.

Start Free with Muni Appeals

Frequently Asked Questions

How do I submit a prior authorization to Molina Healthcare?

Check the service in your state's Molina PA Lookup Tool, then submit medical PA requests through Availity Essentials with clinical documentation attached. Molina Ohio (from January 1, 2026) and Molina Michigan (from February 1, 2026) no longer accept medical PA by fax. Pharmacy PA follows a separate process.

How long does Molina have to decide a Medicaid prior authorization?

For Medicaid managed care contract periods starting on or after January 1, 2026, federal rules cap standard decisions at 7 calendar days and expedited decisions at 72 hours, with possible extensions of up to 14 calendar days (42 CFR 438.210). Your state may require faster decisions.

Can a provider appeal a Molina Medicaid prior authorization denial?

Yes, with the member's written consent where state law permits (42 CFR 438.402). Ordinary Medicaid plan appeals have a 60-calendar-day filing period from the date on the denial notice; a faster state decision deadline does not shorten that right. Use Molina's state authorized-representative form if one is required. Applicable integrated plans follow their integrated appeal process.

Does Molina offer peer-to-peer review for PA denials?

Check whether peer-to-peer review is available for the member's state and product. Use the current denial notice or matching provider manual for the request deadline and phone number; another product's or state's window may not apply.

What happens if Molina upholds my Medicaid PA appeal?

The member can request a State Fair Hearing. Federal rules require states to allow 90 to 120 days from Molina's appeal decision, with the exact window set by the state. If Molina misses its own appeal deadline, the member is treated as having exhausted the plan appeal and can go straight to the hearing.

Is a Molina Medicare Advantage PA appeal different from Medicaid?

Yes. Molina MA denials follow Medicare Part C rules: the treating physician can request a standard pre-service reconsideration after notifying the member, within 60 days of receiving the notice. If Molina upholds the denial, the case goes automatically to the independent review entity, not to a state fair hearing.

Can I request a reconsideration by sending more records?

It depends on the state plan. Some Molina plans route added clinical information through a new Availity request, while others expect a formal appeal. Confirm with your state's Molina provider manual or Provider Services, and keep tracking the 60-day appeal deadline while you wait.

Next Step After a Molina Denial

Start with the denial notice: confirm the product and state, note the peer-to-peer and appeal deadlines, and get member consent signed if this is a Medicaid denial. Then use the matching template above. To see the full Molina cluster, start with the Molina timely filing limits guide or the Molina provider phone numbers by state.

This guide reflects Molina Healthcare prior authorization procedures and federal Medicaid and Medicare Advantage regulations as of October 2026. Molina's PA lists, submission channels, peer-to-peer windows, and appeal deadlines vary by state and product and change during the year. Always confirm current requirements in your state's Molina provider manual, PA Lookup Tool, and the denial notice. This guide is administrative information, not legal advice.