Appeals and grievances in Mississippi

As a Molina Healthcare member, you have the right to file a complaint (grievance) if you have a problem with your medical care or our services. Some examples are:

• The care you get from your provider
• The time it takes to get an appointment or see a provider
• The providers you can choose for care

An appeal can be filed when you do not agree with our decision to:

• Stop, change, suspend, reduce or deny a service
• Deny payment for services provided

Definitions for This Section

“Authorized Representative” means an individual who is authorized to act on Your behalf with respect to a Grievance, either by law or in accordance with Molina’s processes

“Grievance” means any dissatisfaction with Molina that is expressed, in writing, to Molina by You, or Your Authorized Representative:

“Expedited Review” means a review of a Grievance involving an Adverse Determination where the standard resolution process may include any of the following:

• Serious jeopardy to Your life or health (or the life or health of Your unborn child) or Your ability to regain maximum function; or
• In the opinion of the treating physician, would subject You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Grievance; or
• Is determined to be an expedited Grievance by the treating physician

“Standard Review” means a review that does not require a decision to be made on an urgent basis and does not involve any of the conditions listed above in “Expedited Review”.

What if I Have a Complaint, also known as a Grievance?

If you have a problem with any Molina Healthcare services, We want to help fix it.

• You or your authorized representative may file a grievance by phone by calling Molina at (866) 472-9484 (TTY 711) Monday through Friday, 8:00 a.m. to 6:00 p.m., local time. You can also submit your grievance in writing, along with any supporting materials by mail or fax to:

Mail: Attn: Grievance Coordinator

1020 Highland Colony Parkway, Suite 602 Ridgeland, MS 39157

Fax: (844) 808-2407

• You can submit your grievance in writing to the Mississippi Insurance Department:

Mississippi Insurance Department

P.O. Box 79

Jackson, MS 39205-0079

• You can get a complaint form by calling (800) 562-2957 (TTY 711). You can also get a complaint form online at Filing an Online Complaint - Official Website of the Mississippi Insurance Department. You may e-mail it to: consumer@mis.ms.gov.

Molina will acknowledge receipt of the grievance in writing within five business days of receiving it. If your authorized representative filed the grievance on your behalf, We will also provide a notice that health care information or medical records may be disclosed only if permitted by law. We will also include an informed consent form.

Molina will notify you (and/or your authorized representative) in writing of the resolution of your grievance within 30 calendar days from the time we received your written grievance.

For more information, check your member handbook or your agreement and evidence of coverage.

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