You have the right to appeal a denial
An appeal is a request to review a denied service or referral. You can appeal our decision if a service was denied, reduced, or ended early. What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be rendered or bills will not be paid. If we deny your service or claim, you have the right to request why your services or bills were denied. You also have the right to appeal.
If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. This denial letter will tell you about your right to appeal. You can also read about these rights in your Member Handbook.
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How to appeal a denial
If you receive a denial letter from Molina Healthcare, there are four steps in the appeal process:
STEP 1: Molina Healthcare Appeal
STEP 2: State Hearing
STEP 3: Independent Review
STEP 4: Health Care Authority (HCA) Board of Appeals Review Judge
STEP 1 - Molina Healthcare Appeal
You have 90 calendar days after the date of Molina’s denial letter to ask for an appeal. You or your representative may request an appeal or may submit information about your case over the phone, in person, or in writing. You may fax the information to (425) 424-1172. Within 72 hours, we will let you know in writing that we got your appeal. We can help you file your appeal. If you need help filing an appeal, call the (800) 869-7165 (TTY 711).
You may choose someone, including a lawyer or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. Molina does not cover any fees or payments to your representatives. That is your responsibility.
Before or during the appeal, you or your representative may look at your file, medical records, or other documents considered in the appeal. If you want copies of the guidelines we used to make our decision, we can give them to you. We will keep your appeal private. We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent.
Continuation of Services During the Appeal Process
If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process.
Expedited (Faster) Decisions
If you or your provider think waiting for a decision would put your health at risk, ask for an expedited (faster) appeal, state hearing, or Independent Review Organization. Information that you think we need to look at must be given to us quickly. We will review your request and make a fast. If we decide your health is not at risk, we will follow the regular appeal process time to make our decision.
Member Consent Form