Complaints and Appeals

As a Passport by Molina Healthcare (Passport) 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 a Passport decision to: 
 

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

What if I Have a Complaint?

If you have a problem with any Passport services, we want to help fix it. You can call any of the following toll-free for help:

Call Passport toll-free at (833) 644-1621, 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 or by registering to My Molina at www.passporthealthplan.com/members/ky/en-US/pages/home.aspx. Our address is:

Passport by Molina Health Care                                 

Appeals & Grievances

Molina Healthcare, Inc.

PO Box 36030

Louisville, KY 40233-6030

Passport 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.
 

A Member Appeal may be requested by the member or his/her designee orally in person, via telephone, fax, E-mail, or mail within one hundred and eighty (180) calendar days after the member’s receipt of the Notice of Action (NOA). You must follow up your oral appeal or grievance with a written request or we will be unable to process your request.

Expedited Review

If your grievance involves an imminent and serious threat to your health, Passport will quickly review Your grievance. Examples of imminent and serious threats include, but are not limited to, severe pain, potential loss of life, limb, or major bodily function. You will be immediately informed of your right to contact the Department of Insurance. Passport will issue a formal response no later than 24 hours after your initial contact with us. You may also contact the Department of Insurance immediately and are not required to complete the Passport grievance process.
 

Department of Managed Health Care Assistance

The Kentucky 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) 644-1621, 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 thirty (30) days, You may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If You are eligible for IMR, the IMR 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 (800) 595-6053 and a toll-free TTD line ((800) 648-6057) for the hearing and speech impaired. The department’s Internet website at http://insurance.ky.gov/Home.aspx?Div_ID=4 has complaint forms, IMR applications forms and instructions online.
 

Independent Medical Review

You may request an independent medical review (“IMR”) of a Disputed Healthcare Service from the Department of Insurance if You believe that healthcare services have been improperly denied, modified, or delayed by Passport 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 Passport or one of its Participating Providers, in whole or in part because the service is not Medically Necessary.

The IMR process is in addition to any other procedures or remedies that may be available to You. You may have to pay a $25 application or processing fees for an IMR. You have the right to give information in support of the request for an IMR. Passport will give You an IMR application form with any disposition letter that denies, modifies, or delays healthcare services. A decision not to take part in the IMR process may cause You to lose any statutory right to take legal action against Passport regarding the disputed health care service.
 

Eligibility for IMR: Your application for an IMR will be reviewed by Passport by Molina Healthcare. You must have:

1.   Either:
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 Passport 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 Passport or its Participating Provider and the disputed decision is upheld, or the grievance remains unresolved after thirty (30) calendar days. You are not required to wait for a response from Passport for more than thirty (30) calendar days

If Your grievance requires Expedited Review You may bring it immediately to the Department of Insurance attention. You are not required to wait for response from Passport for more than 24 hours.

If Your case is eligible for IMR, 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 decision made in Your case. If the IMR determines the service is Medically Necessary, Passport will provide the healthcare service.

For non-urgent cases, the IMR organization designated by the Department of Insurance must provide its determination within thirty (30) calendar 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 IMR organization must provide its determination within 72 hours.

For more information regarding the IMR process, or to request an application form, please call Passport toll-free at (833) 644-1621. If You are deaf or hard of hearing, call our dedicated TTY at 711.