SchedulerForm

Welcome to Molina Healthcare Peer-to-Peer Online Scheduling

The online P2P Scheduling Tool is currently only for Medicaid Medical P2P Review Requests, not Advanced Imaging, Behavioral Health, or Pharmacy.

“For Advanced Imaging, Behavioral Health or Pharmacy peer-to peer scheduling, please follow the instructions in your denial letter.”

To complete a peer-to-peer request, you will need the following information:

- Requester name and contact information
- Provider name, NPI and contact information
- Patient date of birth and authorization number
- Provider availability

(*) Indicates a required field.

*Is this a Molina Medicaid member?

Yes No

Please select one option

*Has it been more than 5 business days since you received the denial?

Yes No

Please select one option

*Have you started the appeal process for this denial?

Yes No

Please select one option

Peer-to-peer reviews must be requested within 5 business days of receiving a denial letter and before starting the appeal process. Please follow up with the appeals department at:

• To submit a post service dispute use Molina’s provider portal

Requester Information

*Requester First Name:

*Requester Last Name:

*Requester Phone Number:

Requester Cell Phone Number:

*Requester Email:

Provider Information

*National Provider Identification (NPI):

*NPI Category:

*Provider First Name:

*Provider Last Name:

*Provider Group Facility/Name:

*Provider Phone:

Provider Cell Phone:

*Provider Email Address:

Patient and Authorization Information

*Patient Date of Birth:

*Authorization Number:

Provider Availability

Dates/Times Available for Meeting(Please provide 2-3 options)

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.

Request for Peer-to-Peer Review Confirmation

Molina Healthcare has received your request for a peer-to-peer review. The requester will receive an email when the peer-to-peer is scheduled. This is your confirmation, you will not receive an immediate email. Please allow 2 business days for a response, please do not resubmit your request as this could cause a delay in scheduling. Please call Molina Healthcare at (855) 866 - 5462 if you have not received an email after 2 business days.

Confirmation Number

*Authorization Number

Please enter your authorization number

Welcome to Molina Healthcare Peer-to-Peer Online Scheduling

Requester Information

Provider Information

Patient and Authorization Information

Provider Availability

Request for Peer-to-Peer Review Confirmation

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Information

Ease of Use

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