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:
An appeal can be filed when you do not agree with Molina Healthcare’s decision to:
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.
Molina Healthcare, Inc.
Attn: Member Appeals and Grievances
PO Box 182273
Chattanooga, TN 37422
You may also submit by registering to My Molina at https://member.molinahealthcare.com/Member/Login.
Call the Illinois Department of Insurance Office of Consumer Health Insurance External Review toll-free at (877) 850-4740.
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 as described above.
We will send You a letter acknowledging receipt of Your grievance within ten (10) calendar days, if your grievance is submitted in writing. If your grievance is provided by phone, then your initial phone call to Molina will also serve as the acknowledgement. All grievances will then be resolved within sixty (60) calendar days of the date of Your initial contact with us. All levels of grievances will be resolved within sixty (60) calendar days.
A Member Appeal may be requested by the member or his/her designee via phone, fax, E-mail, or mail within one-hundred eighty (180) calendar days after the member’s receipt of the Notice of Action (NOA). If appeal is requested by phone, it must be followed up with a written request within 15 business days. To appoint someone to act on your behalf such as a Friend, Family Member, Provider or Attorney please submit the signed Medical Appeal Request form .
We will send You a letter acknowledging receipt of Your appeal within three (3) business days. All levels of Molina Healthcare’s member appeal procedures will be completed within fifteen (15) business days..
If your appeal involves an imminent and serious threat to your health, Molina Healthcare will quickly review Your appeal. Examples of imminent and serious threats include, but are not limited to, severe pain, potential loss of life, limb, or major bodily function. Molina Healthcare will issue a formal response no later than one (1) calendar day after your initial contact with us. You will be immediately informed of your right to contact the Illinois Department of Insurance Office of Consumer Health Insurance External Review. You may also contact the Department of Managed Health Care immediately and are not required to participate in Molina Healthcare’s grievance process.
The Illinois Department of Insurance is responsible for regulating health care services plans. If You have a grievance against Your health plan, You should first telephone Your health plan toll-free at (833) 644-1623, and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to You. If You need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by Your health plan, or a grievance that has remained unresolved for more than sixty (60) days, You may call the department for assistance. You may also be eligible for an Independent External Review (IER). If You are eligible for IER , the IER process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (877) 850-4740 and TTD for the hearing and speech impaired. The department’s Internet website https://mc.insurance.illinois.gov/messagecenter.nsf has complaint forms, IMR applications forms and instructions online.
You may request an independent external review (“IER ”) of a Disputed Healthcare Service from the Illinois Department of Insurance Office of Consumer Health Insurance External Review if You believe that healthcare services have been improperly denied, modified, or delayed by Molina Healthcare or one of its Participating Providers. A “Disputed Healthcare Service” is any healthcare service eligible for coverage and payment (also called Covered Services) that has been denied, modified, or delayed by Molina Healthcare or one of its Participating Providers, in whole or in part because the service is not Medically Necessary.
The IER process is in addition to any other procedures or remedies that may be available to You. You pay no application or processing fees of any kind for IER . You have the right to give information in support of the request for an IER . Molina Healthcare will give You an IER application form with any disposition letter that denies, modifies, or delays healthcare services. A decision not to take part in the IER process may cause You to lose any statutory right to take legal action against Molina Healthcare regarding the disputed health care service.
Eligibility for IMR: Your application for an IER will be reviewed by the Insurance Office of Consumer Health Insurance External Review to determine:
A. Your provider has recommended a healthcare service as Medically Necessary, or
B. You have received Urgent Care or Emergency Services that a provider determined was Medically Necessary, or
C. You have been seen by a Participating Provider for the diagnosis or treatment of the medical condition for which You seek medical review;
2. The Disputed Healthcare Service has been denied, modified, or delayed by Molina Healthcare or one of its Participating Providers, based in whole or in part on a decision that the healthcare service is not Medically Necessary: and
3. You have filed a grievance with Molina Healthcare or its Participating Provider and the disputed decision is upheld or the grievance remains unresolved after fifteen (15) calendar days. You are not required to wait for a response from Molina Healthcare for more than fifteen (15) calendar days.
If Your grievance requires Expedited Review You may bring it immediately to the Illinois Department of Insurance Office of Consumer Health Insurance External Unit’s attention. You are not required to wait for response from Molina Healthcare for more than one (1) calendar day. The Illinois Department of Insurance Office of Consumer Health Insurance External unit may waive the requirement that You follow Molina Healthcare’s grievance process in extraordinary and compelling cases.
If Your case is eligible for IER, the dispute will be submitted to a medical specialist who will make an independent determination of whether or not the care is Medically Necessary. You will get a copy of the assessment made in Your case. If the IER determines the service is Medically Necessary, Molina Healthcare will provide the healthcare service.
For non-urgent cases, the IER organization designated by the Illinois Department of Insurance Office of Consumer Health Insurance External Unit’ must provide its determination within fifteen (15) business days of receipt of Your application and supporting documents. For urgent cases involving an imminent and serious threat to Your health, including but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of Your health, the IER organization must provide its determination within one (1) calendar day.
For more information regarding the IER process, or to request an application form, please call Molina Healthcare toll-free at (833) 644-1623. If You are deaf or hard of hearing, TTY is provided.