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Complaints and Appeals

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Member Complaint (Grievance) and Appeals

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:

  • The care you get 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.

GRIEVANCES AND APPEALS

Definitions Used in Grievances and Appeals

“Adverse Benefit Determination” means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member’s or applicant's eligibility to participate in this plan, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate.

“External Review or Appeal” means a request by a Member or the Member’s designated representative for an Independent Review Organization to determine whether Molina Healthcare’s Internal Review decisions are correct.

“Final External Review Decision” means a determination by an Independent Review Organization at the conclusion of an External Review or Appeal.

“Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by Molina Healthcare at the completion of the Internal Review or Appeal process, or an Adverse Benefit Determination for which the Internal Review or Appeal process has been exhausted.

“Grievance” means a verbal or written complaint submitted by or on behalf of a Member regarding service delivery issues other than denial of payment for or non-provision of medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or dissatisfaction with the service provided by Molina Healthcare.

“Independent Review Organization” means a certified independent review organization established by the Washington State Insurance Commissioner that is not affiliated with Molina Healthcare.

“Internal Review or Appeal” means the request by or on behalf of a Member to review and reconsider an Adverse Benefit Determination.

 

What if I Have a Complaint (Grievance)?

If You have a problem with any Molina Healthcare services, we want to help.

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. You must file Your Grievance within one hundred eighty (180) days from the day the incident or action occurred which caused You to be unhappy.

You or a person designated by You to assist can contact us by telephone or in writing at:

  • Call Molina Healthcare toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 5:00 p.m. PT. Deaf or hard of hearing Members may dial 711 for the National Relay Service. If You need assistance to file a Grievance in a language other than English or need an accessible format, our Customer Support Center can make arrangements for translation or interpreter assistance.
  • You may also send us Your Grievance in writing by mail or by filing online at our website. Our address is:

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
www.molinahealthcare.com

We will send You a letter acknowledging receipt of Your Grievance within 72 hours of our receipt of the request. Grievances will be resolved within thirty (30) calendar days. Appeals of Adverse Benefit Determinations will be resolved as noted below.

Appeals

When You receive an Adverse Benefit Determination, You can file an appeal with Molina Healthcare.

There are two levels of appeals, an Internal Review or Appeal and an External Review or Appeal. When the Internal Review or Appeal is final, You may request an External Review or Appeal of the Final Internal Adverse Benefit Determination as explained below.

INTERNAL REVIEW OR APPEAL

Requests for Internal Review or Appeal of Adverse Benefit Determinations must be received within 180 days of Your receipt of an Adverse Benefit Determination. Requests for Internal Review or Appeals may be made by calling Molina Healthcare at 888-858-3492 between 8:00 a.m. to 5:00 p.m. PT Monday through Friday, or in writing and sent to the following mailing address or electronic mail address:

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
www.molinahealthcare.com
WAMemberServices@MolinaHealthcare.com

We will send You a letter acknowledging receipt of Your request for Internal Review or Appeal within 72 hours of our receipt of the request. Molina Healthcare’s Internal Review or Appeal procedures will be completed within fourteen (14) calendar days for Adverse Benefit Determinations and twenty (20) calendar days for appeals involving Experimental and Investigational procedures. We may extend the time it takes to make a decision by up to 16 additional days if we notify You of the extension and the reason for the extension. Any further extensions by us are subject to Your informed written consent to an extension. An extension will not extend the time for a determination beyond thirty (30) calendar days without Your written consent.

You may submit information, comments, records and other items to assist in the review. You may review and copy our records and information relevant to the claim free of charge. We will consider all information submitted prior to making our determination. Our review panel will be performed by persons who were not involved in the original decision and who are not subordinates of the persons who made the original decision.

If You are receiving services that are the subject of an Internal Review or Appeal, those services will be continued until the Internal Review or Appeal is resolved if You request the continuation. However, if Molina Healthcare prevails on final determination of the Internal Review or Appeal, You may be responsible for the cost of the coverage received during the review period.

After the Internal Review or Appeal is complete, We will send You a written decision on Your appeal determination and will provide information about what we considered, including the clinical basis for our determination and how You can obtain the clinical review criteria used to help make the decision. If applicable, we will also provide You with information for obtaining an External Review or Appeal of a Final Internal Adverse Benefit Determination.

EXPEDITED REVIEW

You may request an expedited Internal Review or Appeal of an Adverse Benefit Determination if one of the following conditions apply:

  • You are currently receiving or have been prescribed treatment or benefits that would end because of the Adverse Determination.
  • If Your provider believes that a delay in treatment based on the standard review time may seriously jeopardize Your life, overall health or ability to regain maximum function, or would subject You to severe and intolerable pain.
  • If the Adverse Determination is related to an admission, availability of care, continued stay, or emergency health care services and You have not been discharged from the emergency room or transport service.

Requests for expedited Internal Reviews or Appeals may be made in writing or by telephone.

You, a person designated by You to assist, or Your provider may contact us by telephone or in writing at:

  • Call Molina Healthcare toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 5:00 p.m. PT. Deaf or hard of hearing Members may dial 711 for the National Relay Service.
  • Molina Healthcare
    Grievance and Appeals Unit
    P.O. Box 4004
    Bothell, WA 98041
    www.molinahealthcare.com
    WAMemberServices@MolinaHealthcare.com

    Formal responses to an expedited Internal Review or Appeal will be issued no later than 72 hours after Your initial contact with us.

    You may also request a concurrent expedited review of an Adverse Benefit Determination, which means that the Internal Review or Appeal and the External Review or Appeal are handled at the same time. Concurrent expedited reviews are available if one of the following conditions applies:

    • You are currently receiving or have been prescribed treatment or benefits that would end because of the Adverse Determination.
    • If Your provider believes that a delay in treatment based on the standard review time may seriously jeopardize Your life, overall health or ability to regain maximum function, or would subject You to severe and intolerable pain.
    • If the Adverse Determination is related to an admission, availability of care, continued stay, or emergency health care services and You have not been discharged from the emergency room or transport service.

    Requests for concurrent expedited review may be made in writing or by telephone. You, a person designated by You to assist, or Your provider may contact us by telephone or in writing at:

    • Call Molina Healthcare toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 5:00 p.m. PT. Deaf or hard of hearing Members may dial 711 for the National Relay Service.

    Molina Healthcare
    Grievance and Appeals Unit
    P.O. Box 4004
    Bothell, WA 98041
    www.molinahealthcare.com
    WAMemberServices@MolinaHealthcare.com

    Molina Healthcare will issue a formal response no later than 72 hours after Your initial contact with us. Please see below for more information on External Review or Appeals.

    EXTERNAL REVIEW OR APPEAL

    Within 180 days after You have received our Final Internal Adverse Benefit Determination, or if we have not responded to Your request for an Internal Review or Appeal within the time periods noted above, You may request an External Review or Appeal from an Independent Review Organization (“IRO”). Requests for External Review or Appeals must be in writing and sent to the following mailing address or electronic mail address:

    Molina Healthcare
    Grievance and Appeals Unit
    P.O. Box 4004
    Bothell, WA 98041
    www.molinahealthcare.com
    WAMemberServices@MolinaHealthcare.com

    Upon receipt of a valid request for an External Review or Appeal, Molina will arrange for the review from an Independent Review Organization (IRO) at no cost to You, and will provide You with the IRO contact information within 24 hours of selecting the IRO. The IRO is unbiased and not controlled by Us. We will provide the IRO with the appeal documentation, but You may also provide them with information.

    The IRO process is optional and You pay no application or processing fees of any kind. You have the right to give information in support of Your request and have 5 business days from the request for an External Review or Appeal to submit any supporting written information to the IRO. If You are receiving services that are the subject of the appeal, those services will be continued until the matter is resolved by the IRO if You request the continuation. If our Adverse Benefit Determination is upheld by the IRO, You may be responsible for paying for any services that have been continued during the External Review or Appeal.

    The dispute will be submitted to the IRO’s medical reviewers who will make an independent determination of whether or not the care is Medically Necessary or appropriate and the application of this Policy’s coverage provisions to Your health care services. You will get a copy of the IRO’s Final External Review Decision. If the IRO determines the service is Medically Necessary or appropriate for coverage under the Policy, Molina Healthcare will provide the health care service.

    If Your case involves Experimental or Investigational treatment, the IRO will ensure that adequate clinical and scientific experience and protocols are taken into account.

    For non-urgent cases, the IRO must provide its determination within the earlier of fifteen (15) days after the IRO receives the necessary information or twenty (20) days of receipt of Your request.

    You may request an expedited External Review or Appeal if one of the following conditions apply:

    • You receive a Final Adverse Benefit Determination concerning an admission, availability of care, continued stay, or health care service for which You received emergency services and have not been discharged from the facility.
    • You receive a Final Adverse Benefit Determination involving a medical condition for which the standard external review time would seriously jeopardize Your life or health or jeopardize Your ability to regain maximum function.
    • Your request for a concurrent expedited review is granted.

    If the External Review or Appeal is expedited, the IRO must notify You within 72 hours of its Final External Review Decision. If the notice is not in writing, the IRO must provide You with written confirmation of its Final External Review Decision within 48 hours after the date of the decision.

    For more information regarding the External Review or Appeal process, or to request an appeal, please call Molina Healthcare toll-free at 1 (888) 858-3492. If You are deaf or hard of hearing, dial 711 for the National Relay Service.

    Washington State Office of the Insurance Commissioner

    If You have any questions or complaints regarding our handling of Your Grievance or appeal, You may contact the Washington State Office of the Insurance Commissioner. A Washington State Office of the Insurance Commissioner representative will review your issues, and if the representative can’t help you, he or she will point you in the right direction for further assistance.

    Washington State Office of the Insurance Commissioner
    Call 800-562-6900 or
    Call 360-725-7080
    TDD 360-586-0241
    Fax to 360-586-2018
    Email CAP@oic.wa.gov

 

​Language Information

If you, or someone you’re helping, have questions about Molina Marketplace, you have the right to get help and information in your language at no cost.To talk to an interpreter, call 1-888-858-3492.

Información de idioma

Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Molina Healthcare tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete,llame al 1-888-858-3492.

语言信息

如果您,或是您正在協助的對象,有關於[插入SBM項目的名稱 Molina Marketplace 方面的 問題,您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員,請撥電話 [在此插入數字 1-888-858-3492。

Thông Tin Ngôn Ngữ

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Molina Marketplace, quý vị sẽ cóquyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-888-858-3492.

​언어 정보

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Molina Marketplace 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는1-888-858-3492 로 전화하십시오.

​Информация о языках

Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Molina Marketplace,то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1-888-858-3492.

Impormasyon sa Wika

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Molina Marketplace, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-888-858-3492.

Выберите язык

Якщо у Вас чи у когось, хто отримує Вашу допомогу, виникають питання Molina Marketplace, у Вас є право отримати безкоштовну допомогу та інформацію на Вашій рідній мові. Щоб зв’язатись з перекладачем, задзвоніть на 1-888-858-3492.

​សេវាកម្មភាសា

ប្រសិនបើអ្នក ឬនរណាម្នាក់ដែលអ្នកកំពុងតែជួយ មានសំណួរអំពី Molina Marketplace ទេ, អ្នកមានសិទ្ធិទទួលជំនួយនិងព័ត៌មាន នៅក្នុងភាសា របស់អ្នក ដោយមិនអស់ប្រាក់ ។ ដើម្បីនិយាយជាមួយអ្នកបកប្រែ សូម 1-888-858-3492 ។

言語情報

ご本人様、またはお客様の身の回りの方でも、Molina Marketplace についてご質問がございま したら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金 はかかりません。通訳とお話される場合、1-888-858-3492 までお電話ください。

የቋንቋ መረጃ

እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ Molina Marketplace ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ 1- 888-858-3492 ይደውሉ።

​Afaan odeeffannoo

Isin yookan namni biraa isin deeggartan Molina Marketplace irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu. Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-888-858-3492 tiin bilbilaa.

معلومات اللغة

إن كان لديك أو لدى شخص تساعده أسئلة بخصوص Molina Marketplace, فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ 3492-858-888-1 .

ਭਾਸ਼ਾ ਦੀ ਜਾਣਕਾਰੀ

ਜੇ ਤੁਹਾਨੰ ੂ , ਜ􀁿 ਤੁਸੀ ਿਜਸ ਦੀ ਮਦਦ ਕਰ ਰਹੇ ਹੋ , Molina Marketplace ਕੋਈ ਸਵਾਲ ਹੈ ਤ􀁿, ਤੁਹਾਨੰ ੂ ਿਬਨਾ ਿਕਸ ੇ ਕੀਮਤ 'ਤੇ ਆਪਣੀ ਭਾਸ਼ ਿਵੱਚ ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਪ􀂇ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ . ਦੁਭਾਸ਼ੀ ਨਾਲ ਗੱਲ ਕਰਨ ਲਈ, 1-888-858-3492 ਤੇ ਕਾਲ ਕਰੋ .

Sprachinformation

Falls Sie oder jemand, dem Sie helfen, Fragen zum Molina Marketplace haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-888-858-3492 an.

ຂໍ້ມູນພາສາ

ຖ້າທ່ານ, ຫຼືຄົນທີ່ທ່ານກໍາລັງຊ່ວຍເຫຼືອ, ມີຄໍາຖາມກ່ຽວກັບ Molina Marketplace, ທ່ານມີສິດທີ່ຈະໄດ້ຮັບການຊ່ວຍເຫຼືອແລະຂໍ້ມູນຂ່າວສານທີ່ເປັນພາສາຂອງທ່ານບໍ່ມີຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1-888-858-3492.

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