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Members

How to Appeal a Denial

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You have the right to appeal a denial

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 prior authorization, 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 letter will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

Member Services staff can also help you file an appeal. If you are not happy with the result of your appeal for a disputed healthcare service, you can ask for a second opinion. This means providers outside Molina Healthcare review all the facts in your case and make a decision. We will accept that finding.

Would you like to ask for a review of an appeal? Call Member Services and ask them to help set this up for you.

How to appeal a denial

If you receive a Notice of Action from Molina Healthcare, you have two (2) options for filing an appeal. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred, or modified.

  • Members have ninety (90) days from the date on the Notice of Action to file an appeal with Molina Healthcare. Members may file an appeal in person, in writing, by e-mail, fax, TTY 7-1-1 or telephone. Molina must write you within 10 days and let you know we received your appeal. Molina must provide written notice of a decision within 30 days unless it is an expedited review. The maximum time Molina can take to resolve a grievance or appeal is 45 days.
  • Members may request a State Fair Hearing from the Department of Health Services (DHS) within forty five (45) days.

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