As a Molina Healthcare member, if you have a problem with your medical care or our services, you have a right to file a complaint (grievance) or appeal. Some examples are:
- You are unhappy with the care you received from your provider
- The time it takes to get an appointment or be seen by a provider.
- The providers you can choose for care.
An appeal can be filed when you do not agree with Molina Healthcare’s decision to:
- Stop, change, suspend, reduce or deny a service.
- Deny payment for services provided.
What if I Have a Complaint?
If you have a problem with any Molina Healthcare services, we want to help fix it. You can call any of the following toll-free for help:
Call Molina Healthcare toll-free at (833) 644-1623, Monday to Friday, 8:00 a.m. - 6:00 p.m. TTY users can dial 711.
You may also send us your problem or complaint in writing by mail, to appoint someone to act on your behalf such as a Friend, Family Member, Provider or Attorney please submit the signed grievance form.
By Mail:
NV Grievance and Appeals
Molina Healthcare Inc
PO Box 182273
Chattanooga, TN 37422
Fax: (833)412-3145
Member Grievance Request Form
Molina Healthcare recognizes the fact that Members may not always be satisfied with the care and services provided by our contracted doctors , hospitals and other providers. We want to know about Your problems and complaints. You may file a grievance (also called a complaint) in person, in writing, or by telephone.
We will send You a letter acknowledging receipt of Your grievance within five (5) calendar days and will then issue a formal response within thirty (30) calendar days of the date of your initial contact with us.
Appealing Resolution of Grievances
If you are not satisfied with the resolution, you can appeal that resolution in writing. You have a right to appear in person before an Internal Appeals & Grievance (A&G) Review Board or address a written appeal to the Internal A&G Review Board.
We will send you an acknowledgment letter within five calendar days of receipt of the appeal. Appeals will be resolved within thirty (30) calendar days from the receipt of the appeal.
The majority of the A&G Review Board will be composed of Molina Members and include Molina staff members, physicians, or other providers. A member of an Internal A&G Review Board may not have been previously involved in the disputed decision. The physicians or other providers on an Internal A&G Review Board will have experience in the care that is in dispute and must be independent of any physician or provider who made any previous determination. If specialty care is in dispute, the Internal A&G Review Board will include a person who is a Specialist Physician in the field of care to which the appeal relates. The Molina Members of an Internal A&G Review Board will not be employees of Molina.
Expedited Review
If your grievance involves an imminent and serious threat to your health, we will quickly review your grievance. Examples of imminent and serious threats include but are not limited to, severe pain, and potential loss of life, limb, or major bodily function. You will be immediately informed of your right to contact the Office for Consumer Health Assistance. We will issue a formal response no later than three (3) calendar days after your initial contact with us. You may also contact the Office for Consumer Health Assistance immediately and are not requested to participate in our grievance process.
Appointing a Representative
If you would like someone to act on your behalf regarding a complaint/grievance or a standard or expedited appeal, you may appoint an Authorized Representative. In the event a Provider files an Appeal on your behalf, the Provider must first obtain your written permission including for an expedited appeal.
Appointment of a Representative Form
Initial Denial Notice
You will be provided with a Notice of Adverse Benefit Determination by mail. An Adverse Benefit Determination notice will identify the claim or authorization request involved. It will give the specific reason for the Adverse Benefit Determination (including the denial code and its meaning) and the specific product provisions upon which the determination was based. It will also include the contact information for the Office for Consumer Health Assistance, which is available to assist with the internal and external appeal processes. Upon request, a copy of the rule, protocol, or similar criterion relied upon to deny the claim or authorization request will be provided, free of charge. The notice will describe Molina's internal and external (standard and expedited) appeal procedures, and the time limits applicable to such procedures following an Adverse Benefit Determination and will include a release form authorizing Molina to disclose protected health information pertinent to an external review.
Internal Appeal Process
Adverse Benefit Determinations must be appealed within 180 calendar days after receiving written notice of the denial (or partial denial). You may appeal an Adverse Benefit Determination by means of notice to us either in person, by phone, or by mail.
The request should include:
• The date of the request.
• Member’s name (please print or type).
• The date of the denied service.
• The Member’s identification number
• Claim or Prior Authorization number, and
• Provider name.
You have the option of presenting evidence and testimony to us. You may ask to review the file and any relevant documents and may submit written issues, comments, and additional medical information within 180 days after receiving the notice of an Adverse Benefit Determination or at any time during the appeal process.
You may request an expedited internal appeal of an Adverse Benefit Determination involving Urgent Care Services. Before authorization of benefits for an ongoing course of treatment or concurrent or continued hospitalization is terminated or reduced, we will provide you with notice and an opportunity to request an expedited appeal. For the ongoing course of treatment, coverage will continue during the appeal process.
Determination of appeals of Adverse Benefit Determinations will not be made by the person who made the initial Adverse Benefit Determination or a subordinate of that person. You have the right to request that the person performing the review must practice the same profession as the attending health care provider.
Member Appeal Request Form
Exhaustion of the Internal Appeal Process
A request for standard or expedited external review cannot be made until our internal appeals process has been exhausted (completed) and a Final Adverse Benefit Determination has been provided, unless 1) We provide a waiver of this requirement, 2) We fail to follow the internal appeal process, or 3) if you file a request for an expedited external review at the same time as an internal expedited grievance involving an Urgent Care Service as certified by the treating Provider.
External Review
After receipt of a Final Adverse Benefit Determination or if otherwise permitted, as described above, you may request an external review if you believe that a healthcare service has been improperly denied, modified, or delayed on the grounds that the healthcare service doesn’t meet our requirements for Medical Necessity, appropriateness, health care setting, level of care, the effectiveness of a covered benefit, or is Experimental or Investigational. You must authorize the release of any medical records required for reaching a decision on the external review.
An Independent Review Organization (IRO) will conduct an external review. We will not choose or influence the IRO’s reviewers.
There are three types of IRO reviews:
1. Standard External Review: The IRO will provide written notice of its decision within 15 calendar days of its receipt of the request for standard external review.
2. Expedited External Review: Expedited reviews for an Urgent Care Service, including reviews of Experimental or Investigational treatment involving an Urgent Care Service are normally completed within 72 hours. Expedited review can be requested for Urgent Care Service as certified by the treating Provider or concerning Emergency Services for which the Member has not yet been discharged.
3. External Review of Experimental and Investigational Treatment: For a standard or expedited external review for a determination that a treatment is Experimental or Investigational, the treating Provider must be qualified in the relevant area of medicine and must certify that the treatment is medically appropriate.
Request for External Review:Requests must be made, in writing, within 4 months of the date of the notice of Adverse Benefit Determination or Final Adverse Benefit Determination for a standard review. A request for an expedited external review has no filing deadline. You can submit a written request for external review, along with any supporting materials, to the Office for Consumer Health Assistance at:
State of Nevada Office for Consumer Health Assistance
3320 W. Sahara Avenue, Suite 100
Las Vegas, NV 89102
Phone: 702-486-3587 or toll-free 888-333-1597
Fax: 702-486-3586
Email: CHA@govcha.nv.gov
Online complaint form: https://adsd.nv.gov/Programs/CHA/ExtRev/External_Review/
IRO Assignment: For an external review, the Office for Consumer Health Assistance (OCHA) will utilize an impartial and independent rotational system to assign the review to a Nevada-accredited Independent Review Organization (IRO) that is qualified to conduct the review based on the type of health care service. OCHA will verify that no conflict of interest exists with the IRO.
IRO Review and Decision: Within 5 business days after the IRO’s receipt of a request for standard external review, the IRO will determine whether the request is eligible for external review and confirm that all information, forms, and certifications were provided. The IRO will notify you immediately if additional information is required. If the request is not accepted for standard external review, the IRO will provide you and Molina with written notice explaining the reason. The IRO will notify you and Molina if the request is accepted for standard external review. This paragraph does not apply to expedited external reviews.
The IRO will provide written notice of its decision within 15 calendar days of its receipt of the request for a standard review. The IRO will provide notice of an expedited review decision within 72 hours of receipt of a request for an expedited review. If the expedited review decision is not in writing, a written notice will be provided within 48 hours of providing the oral notice. If the IRO reverses the Adverse Benefit Determination or Final Adverse Benefit Determination, Molina will approve a covered benefit that was the subject of a standard request within five business days of receipt of the notice from the IRO, and as quickly as reasonably possible for an expedited request, subject to applicable exclusions, limitations, or other provisions of this Agreement.
Binding Nature of External Review Decision: An external review decision is binding on Molina except to the extent Molina has other remedies available under State Law. The decision is also binding on you except to the extent that you have other remedies available under applicable State Law or federal law. You may not file a subsequent request for an external review involving the same Adverse Benefit Determination that was previously reviewed.
State Regulator Assistance
For questions about your rights or for assistance with complaints, with the internal claims and appeals process, or with the external review process, you may contact the Office for Consumer Health Assistance at the following:
State of Nevada Office for Consumer Health Assistance
3320 W. Sahara Avenue, Suite 100
Las Vegas, NV 89102
Phone: 702-737-6180 or 888-333-1597
Fax: 702-486-3586
E-mail: CHA@nv.gov
Online complaint form: https://adsd.nv.gov/Programs/CHA/ExtRev/External_Review/
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