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Guide to Provider Forms (Molina Healthcare)

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27613_OH_2022_Medicaid_PIF.indd 127613_OH_2022_Medicaid_PIF.indd 1 2/11/22 11:10 AM2/11/22 11:10 AM
ACTION YOU WILL NEED TO COMPLETE THE SECTIONS IDENTIFIED BELOW ON THE
PROVIDER INFORMATION UPDATE FORM (PIF) AND ANY ADDITIONAL DOCUMENTS
LISTED. ALL DOCUMENTS MUST BE COMPLETED AND RETURNED
Add a Provider to
the group
•
•
•
•
* and Section O PIF – Complete Section A, Section N
* Section N can be copied when adding multiple providers
Attachment A (Primary Care Providers, Specialists and Ancillary
Providers)
Attachment B (Hospital Services)
CAQH (if applicable)
Individua
l:
Change or add a service
location
•
•
•
PIF – Complete Section A, Section H and Section O
Attachment A (Primary Care Providers, Specialists and Ancillary
Providers)
Attachment B (Hospital Services)
Change Phone/Fax
• PIF – Complet
e Section A, Section F and Section O
Change the Pay-To/
Billing Address
•
•
PIF – Complete Section A and Section I
W-9
• Sample Claim Form (de-identied)
Group:
Change or add a service
location
•
•
•
•
PIF – Complete Section A, Section G and Section O
Attachment A (Primary Care Providers, Specialists and Ancillary
Providers)
Attachment B (Hospital Services)
ADA Attestation Form
Guide to Provider Forms
27613FRMMDOHEN
MHO-2452
0122
27613_OH_2022_Medicaid_PIF.indd 227613_OH_2022_Medicaid_PIF.indd 2 2/11/22 11:10 AM2/11/22 11:10 AM
Add a new group to the
same Tax Identication
Number (TIN)
•
•
•
•
•
PIF – Complete Section A
W-9
Attachment A (Primary Care Providers, Specialists and Ancillary
Attachment B (Hospital Services)
Providers)
Sample Claim Form (de-identied)
Change Gr
oup
Nam
e Only
•
•
•
•
•
PIF – Complete Section A and Section D
Attac
hment A (Primary Care Providers, Specialists and Ancillary
Providers) with new group name
Attachment B (Hospital Services) with new group name
Sample Claim Form (de-identied)
W-9
Change TIN only
•
•
PIF – Co
mplete Section A and Section B
W-9
• Sample Claim Form (de-indentied)
Individual Name
Change
•
•
•
PIF – Complete Section A and Section E
Attachment A (Primary Care Providers, Specialists and Ancillary
Providers)
A
ttachment B (Hospital Services)
Terming a provider
• See Se
ction J for instructions
Provider
Directory Update
• PIF – Complete Section A and Section L
Panel Upd
ate • PIF – Complete Section A and Section K
Hospit
al
Aliations Update
• PIF – Complete Section A and Section M
Group/In
dividual NPI
or Medicaid ID
Change/Addition
• PIF – Complete Section A and Sectio
n C
27613_OH_2022_Medicaid_PIF.indd 327613_OH_2022_Medicaid_PIF.indd 3 2/11/22 11:10 AM2/11/22 11:10 AM
FORMS: FORM USAGE:
Provider Information
Update Form (PIF)
is form is used to communicate changes, deletions and additions regarding
participating providers to Molina Healthcare.
Attachment A is form is used for all Primary Care Providers (PCPs), Specialists and
Ancillary Providers.
Attachment B is form is used for all hospitals and hospital services.
W-9 is document is issued by the U.S. Internal Revenue Service (IRS). Molina
Healthcare uses it to update the TIN owner name, doing business as name, and
Tax ID when received with a PIF.
ADA Attestation Form Providers use this form to attest to their compliance with American Disabilities
Act (ADA) requirements for each physical service location.
Credentialing -
Individual Providers
YOU WILL NEED TO…
If you have a
CAQH number
Complete CAQH Provider Data Form. You also need to update and give Molina
Healthcare permission to review. Visit the website at http://www.caqh.org.
If you do not have a
CAQH number
Go to http://www.caqh.org to request a CAQH number and ll out the
information. You will need to give permission to Molina Healthcare to review.
Credentialing -
Facilities and Other
Providers
YOU WILL NEED TO …
Including Hospitals,
Ambulatory
Surgical Centers,
Home Health Agencies,
Durable Medical
Equipment (DME)
Suppliers, SNFs, Urgent
Care Centers, and
Retail Clinics
Print, complete, fax, email or mail the Ohio Department of Insurance
Standardized Credentialing Form Part B (Molina Healthcare refers to this as
“HDO”). is form can also be found at Quicklinks located at
http://www.insurance.ohio.gov.
Molina Healthcare of Ohio
Attention: PIM
P.O. Box 349020
Columbus, OH 43234-9904
Fax: (866) 713-1893
Email: MHOProviderUpdates@MolinaHealthCare.com
CONTACT
INFORMATION
If you have additional questions please contact Molina Healthcare’s Provider
Services department at (855) 322-4079 between the hours of 8 a.m. to 5 p.m. EST,
Monday through Friday.
27613_OH_2022_Medicaid_PIF.indd 427613_OH_2022_Medicaid_PIF.indd 4 2/11/22 11:10 AM2/11/22 11:10 AM
Provider Information Update Form (PIF)
Submission Date
is form and the associated documentation are required to notify Molina Healthcare of Ohio of any changes to
your group/practice information and/or to begin the credentialing process. is form is also available
at www.MolinaHealthcare.com.
Type of Group/Provider (Select all that apply):
PCP Specialist Dental BH - Private Practice BH - CMHC/SUD
Ancillary LTSS FQHC/RHC QFPP/Title X Urgent Care Hospital
CMHC/SUD Agencies Only: For any entity/organization-level updates, please use this form.
All updates to employed rendering providers at a CMHC/SUD must be made through the Ohio Department
of Medicaid/MITS System.
All Providers: If changing your Group/Practice Name and Tax ID Number, an Amendment is required.
However, if changing the Group/Practice Name and Tax ID due to an ownership change, a new contract may
be required. Please contact Molina Healthcare Provider Services at (855) 322-4079.
A representative will be available to assist you Monday through Friday, 8 a.m. - 5 p.m. EST.
SECTION A
Current Group/Practice Information (All felds in this section are required)
Group/Practice Name:
Group/Practice Tax ID: Group/Practice Medicaid #:
Group/Practice NPI #: Contact Number:
Email Address: Contact Name:
Tax Exempt Yes No
Return to frst page.
SECTION B
Tax ID Number Change Eective Date
Previous Tax ID Number: New Tax ID Number:
Return to frst page.
/ /
/ /
SECTION C
Group/Individual NPI or Medicaid ID Change/Addition Eective Date / /
☐ Group NPI ☐ Individual NPI
(If adding an NPI, do not 
ll out "Previous NPI" lin
e.)
Group/Individual Name:
Previous NPI:
New NPI:
☐ Group Medicaid ID ☐ Individual Medicaid ID
(If adding a Medicaid ID, do not ll out "Previous Medicaid ID" line.)
Previous Medicaid ID:
New Medcaid ID:
Return to rst page.
SECTION D
Group/Practice Name Change Eective Date / /
Previous Group/Practice Name: Medicaid #:
New Group/Practice Name: Medicaid #:
Return to rst page.
OTHER CHANGES
SECTION E
Individual Name Change Eective Date / /
Previous Name: New Name:
Return to rst page.
SECTION F
Change Phone/Fax Eective Date / /
Previous Phone Number: New Phone Number:
Previous Fax Number: New Fax Number:
Address: City, State, Zip:
Return to rst page.
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Section G (Group)
☐ Add a Service Location Eective Date / /
☐ Change a Service Location
Is location closing: Y ☐ N ☐
Please complete the ADA Attestation Form for all new Service Locations.
Previous Address New Address
Service Location Name: Service Location Name:
Address 1: Address 1:
Address 2: Address 2:
City, State, Zip: City, State, Zip:
Phone Number: Phone Number:
Fax Number: Fax Number:
Email: Email:
Return to rst page.
Section H (Individual)
☐ Add a Provider to a Service Location Eective Date / /
☐ Change Service location for a Provider
Previous Address New Address
Service Location Name: Service Location Name:
Address 1: Address 1:
Address 2: Address 2:
City, State, Zip: City, State, Zip:
Phone Number: Phone Number:
Fax Number: Fax Number:
Email: Email:
Return to rst page.
27613_OH_2022_Medicaid_PIF.indd 627613_OH_2022_Medicaid_PIF.indd 6 2/11/22 11:10 AM2/11/22 11:10 AM
SECTION I
Billing Address Change Eective Date / /
Previous Billing Information New Billing Information
Billing Contact: Billing Contact:
Address 1: Address 1:
Address 2: Address 2:
City, State, Zip: City, State, Zip:
Phone Number: Phone Number:
Fax Number: Fax Number:
• Is this a Notice Address Change? ☐ No ☐ Yes
e Noti
ce Address is the part
icular party’s address for delivery or mailing of notice purposes.
Return to rst page.
SECTION J
Terminating a Provider
A termination letter is required on company letterhead and must include the following: Group Name, Group
Tax ID, Group NPI, name of the provider to be termed, Provider NPI, eective date of termination, reason for
termination and address of practice location(s). If terming provider is a PCP, include name of provider that will
assume patient panel.
Return to rst page.
SECTION K
Panel Update Eective Date / /
☐ Existing Patients ☐ Only Close Panel to all Members ☐ Open Panel
Reason: (Required)
Return to rst page.
SECTION L
Provider Directory Update Eective Date / /
☐ Include in Provider Directory ☐ Exclude from Provider Directory
Reason: (Required)
Return to rst page.
27613_OH_2022_Medicaid_PIF.indd 727613_OH_2022_Medicaid_PIF.indd 7 2/11/22 11:10 AM2/11/22 11:10 AM
SECTION M
Hospital Aliations Update Eective Date / /
☐ Add Hospital Aliation(s) ☐ Remove Hospital Aliation(s)
Names of Hospital(s):
Return to rst page.
27613_OH_2022_Medicaid_PIF.indd 827613_OH_2022_Medicaid_PIF.indd 8 2/11/22 11:10 AM2/11/22 11:10 AM
SECTION N
Provider Joining a Group/Practice Eective Date / / Locum Tenen: ☐ Y ☐ N
Provider Name (Last, First, MI):
Provider Type (MD, DO, DC, DDS, DPM, etc): Date of Birth:
Last Four Digits of Social Security #: Provider Ethnicity:
☐ African American ☐ Caucasian
☐ Asian/Pacic Islander ☐ Hispanic
☐ Alaskan/American Indian ☐ Other
Individual Provider NPI Number: CAQH Provider Number:
Note: Please ensure the provider has completed and/or re-attested to the CAQH Application and authorized
Molina Healthcare to access CAQH.
OH Medicaid Number: OH Medicare Number:
Specialty: Secondary Specialty:
Applying as: ☐ PCP ☐ Specialist ☐ Hospitalist ☐ Other
For Behavioral Health Providers: Are you individually accessible by appointment? ☐ Yes ☐ No
Board Certied: ☐ Yes ☐ No Eective Date / / Expiration Date / /
Certication Board:
Group/Practice Name:
Group/Practice Address:
City, State, Zip:
Phone Number: Fax Number:
Email Address:
Return to rst page.
(Provider must have an active Medicaid Number)
For Nurse Practioners,
Physician Assistants
and Nurse Midwives
only:
Supervising Physician Name & Degree Supervising Physician Specialty:
27613_OH_2022_Medicaid_PIF.indd 927613_OH_2022_Medicaid_PIF.indd 9 2/11/22 11:10 AM2/11/22 11:10 AM
27613_OH_2022_Medicaid_PIF.indd 1027613_OH_2022_Medicaid_PIF.indd 10 2/11/22 11:10 AM2/11/22 11:10 AM
Section O
Oce Hours
From To
Monday
Tuesday
Wednesday
ursday
Friday
Saturday
Sunday
Return to frst page.
If you have any questions, visit our website at www.MolinaHealthcare.com or call Provider Services at
(855) 322-4079. Representatives are available to assist you Monday through Friday from 8 a.m. to 5 p.m.
Please mail, fax or email this form and supporting documentation to:
Molina Healthcare of Ohio
Attn: PIM
P.O. Box 349020 Columbus, OH 43234-9904
Fax (866) 713-1893
MHOProviderUpdates@MolinaHealthcare.com
Return to frst page.
(Ancillary pr viders are not required to list emplo ees on this attachment. Ancillary, Urgent Care, FQHC and RHC providers: List each service location.)
27613_OH_2022_Medicaid_PIF.indd 1127613_OH_2022_Medicaid_PIF.indd 11 2/11/22 11:10 AM2/11/22 11:10 AM



Ohio Department of Medicaid
MANAGED CARE ENTITY (MCE) – GROUP PROVIDER AFFILIATIONS – ATTACHMENT A
Ohio Department of Medicaid
MANAGED CARE ENTITY (MCE) – GROUP PROVIDER AFFILIATIONS – ATTACHMENT A
Provider Group Name
MCE Name
Molina Healthcare of Ohio, Inc.
Group Tax ID Number
Group NPI
*
Group Medicaid ID
*
*Please submit a separate Attachment A for any given Group/Location NPI and/or Group Medicaid ID.
(Groups should provide Group name, NPI and Tax ID Number above and individual practitioner NPI under “Provider NPI” below.)
(Ancillary providers are not required to list employees on this aachment. Ancillary, Urgent Care, FQHC and RHC providers: List each service locaon.)
Last First MI Spec Service Location (Name and Street Address) Provider Medicaid ID Provider NPI
Capacity
(PCP only)
MCE acknowledges changes on the date received. Effective Date will be determined by the MCE. Each rendering provider’s name must be listed. “Capacity” represents the
maximum number of the MCE’s Medicaid members primary care providers (PCP) agree to serve. Please indicate a numeric capacity value instead of “unlimited” or similar
response. For any given PCP, total capacity must not exceed 2,000 across all locations. If multiple pages are used, the pages must be numbered sequentially on every page (e.g.,
1 of 3, 2 of 3, and 3 of 3).
Return to frst page.
ODM 10231 (Rev. 7/2021)
27613_OH_2022_Medicaid_PIF.indd 1227613_OH_2022_Medicaid_PIF.indd 12 2/11/22 11:50 AM2/11/22 11:50 AM
Ohio Department of
Medicaid
MANAGED CARE ENTITY (MCE) – HOSPITAL SERVICES ATTACHMENT B
The provider must complete a copy of this form for each hospital covered by the terms and conditions of this
addendum. If multiple pages are used, the pages must be numbered sequentially on every page (e.g., 1 o
f 3, 2 of 3,
and 3 of 3) and the signature block must be included on each page. MCE acknowledges changes on the date received.
Effective Date will be determined by the MCE.
Mo
lina Healthcare of Ohio, Inc.
Hospital Information
Hospital Name
Address
City
State
Zip
County
Tax ID Number
NPI
Secondary NPI
1. Hospital Services Categories
Please check the applicable line for each category of service the above-named hospital covers.
Surgical Services Neonatal IntensiveCare - Level 3 Special Care
Pediatric Surgical Services Adult Intensive Care Outpatient Psychiatric Services
Obstetrical Services Midwife Services Practitioner Services
Nursery Services Outpatient Surgery
Other
(Please specify)
Nursery Services Level 1 & 2 Pediatric Intensive Care
2. Hospital does not provide the following hospital service(s) because of an objection on moral or religious grounds.
List services:
Return to frst page.
ODM 10233 (Rev.8/ 2021)
27613_OH_2022_Medicaid_PIF.indd 1327613_OH_2022_Medicaid_PIF.indd 13 2/11/22 11:10 AM2/11/22 11:10 AM
Please complete the following attestation for each provider service location and return it with your signed
contract:
Provider Name: Tax ID #or SSN:
Address: Phone:
Email Address:
e Americans with Disabilities Act ( ) and Ohio Administrative Code ( ) 3781.111 require providers
make reasonable access and accommodations for all persons with disabilities. Molina is providing you with the
opportunity to self-attest to the below
OAC
standards in order to verify core elements of compliance for
the MyCare Ohio program.
ADAADA
ADA
If you are not an oce-based provider, please check here and proceed to the signature section below: £
If you are an oce-based provider, please check the applicable box next to each standard below and have the
designated representative sign and return the attestation to Molina Healthcare.
ADA STANDARDS YES NO
Building has handicap designated parking. Parking spaces are accessible with ramps and curb
cutouts between the parking lot, oce, and at drop o locations.
Building has automatic entry option or alternative access method.
Building has elevator for public use (if building is multi-leveled). Elevator has enough room for
the wheelchair and/or scooter to maneuver.
Restroom is equipped with large stall and safety bars or other reasonable accommodations.
Waiting room (including furniture) can accommodate patients with physical and non-physical
disabilities. e reception and waiting areas have enough room for a wheelchair and/or scooter
to maneuver and turn around.
At least one exam room can accommodate patients with physical and non-physical disabilities.
Signage and way nding is clear (e.g. color, symbol signage, and braille).
Doors to access building, oce, and patient rooms are at least 32 inches wide.
e exam table moves up and down to make it easier to get on and o whether standing or
using a wheelchair or scooter.
Diagnostic equipment can accommodate patients with disabilities.
e scale is able to accommodate a wheelchair or scooter.
Provider service locations that attest to being compliant or have received an in-oce assessment and
determined to be compliant will be published as such in the Molina MyCare Ohio Provider Directory. ADA
ADA
I attest to the best of my knowledge that the above information is true, accurate and complete.
Name: Signature:
Title: Date:
If you have any questions or concerns, please contact Molina Healthcare Provider Relations at (855) 322-4079.
ank you for your prompt response.
Molina Healthcare of Ohio • P.O. Box 349020 • Columbus, OH 43234-9020
www.MolinaHealthcare.com
Return to frst page.
MHO-1768
0721
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Completed 6 July 2022

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