COMPLAINTS
What is a Complaint?
A complaint is any dissatisfaction that You have with Molina or any Participating Provider that is not related to the denial of healthcare services. For example, You may be dissatisfied with the hours of availability of Your doctor. Issues relating to the denial of health care services are Appeals, and should be filed with Molina or the Ohio Department of Insurance in the manner described in the Internal Appeals section below.
Molina recognizes the fact that you 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 concerns and any complaints you may have. We will respond to your complaint no later than 60 days from the date we received it.
You may contact Molina for assistance with filing your complaint over the phone, by mail or fax using the following contact information.
| Appeals and Grievances Department |
| Address: |
Molina Healthcare of Ohio, Inc. Appeals and Grievance Department
P.O. Box 349020
Columbus, Ohio 43234-9020 |
| Telephone: |
(888) 296-7677,
Monday – Friday 8:00 am – 6:00 pm EST |
| TTY: |
(800) 750-0750 or 711 |
| Website: |
www.molinahealthcare.com |
You may also contact the Ohio Department of Insurance
CLAIMS DECISIONS, INTERNAL APPEALS, AND EXTERNAL REVIEW
Definitions
- For the purposes of this section,“Adverse Benefit Determination” means a decision by Molina to deny, reduce, or terminate a requested health care service or payment in whole or in part, including all of the following:
- A determination that the health care service does not meet Molina’s requirements for Medical Necessity, appropriateness, health care setting, level of care, or effectiveness,including Experimental or Investigational treatments;
- A determination that a health care service is not a Covered Service;
- The imposition of an exclusion source of injury, network, or any other limitation on benefits that would otherwise be covered.
- Not to issue individual health insurance coverage to an applicant, including initial eligibility determinations;
- To rescind coverage on a health benefit plan.
“Final Adverse Benefit Determination” means an Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Molina, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.
"Urgent care services" means a medical care or other service for a condition where application of the timeframe for making routine or non-life threatening care determinations is either of the following:
- Could seriously jeopardize the life, health, or safety of the patient or others due to the patient's psychological state;
- In the opinion of a practitioner with knowledge of the patient's medical or behavioral condition, would subject the patient to adverse health consequences without the care or treatment that is the subject of the request.
Appointing a Representative
If a Member would like someone to act on his/her behalf regarding a claim or an appeal of an Adverse Benefit Determination the Member may appoint an authorized representative. Members should send the representative’s name, address, and telephone contact information to:
| Appeals and Grievances Department |
| Address: |
Molina Healthcare of Ohio, Inc. Appeals and Grievance Department P.O. Box 349020 Columbus, Ohio 43234-9020 |
| Telephone: |
(888) 296-7677,Monday – Friday 8:00 am – 6:00 pm EST |
| TTY: |
(800) 750-0750 or 711 |
| FAX: |
(866) 713-1891 |
You must pay the cost of anyone You hire to represent or help You.
CLAIMS DECISIONS
After a determination on a claim is made, We will notify You of a favorable determination or Adverse Benefit Determination within a reasonable time, as follows:
| Request Types |
Time Frame for Decision |
Time Frame for Notification of Decision |
| Pre-Service Claim |
Within forty-eight hours for urgent care services, or ten calendar days for any priorauthorization request that is not for an urgent care service, of the time the request is received.(If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
Within forty-eight hours for urgent care services, or ten calendar days for any prior authorization request that is not for an urgent care service, of the time the request is received.(If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial.Molina will inform you of the reason for denial.) |
| Concurrent Service Claim |
24 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
24 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
| Post-Service Claim |
30 days from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
30 days from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
Please Note:
Additional information requests for Urgent Care Services will be made within 24 hours in accordance with state law.
If medical necessity is determined on appeal and a prior authorization is required for the benefit the determination will also include the authorization of the benefit in the determination.
Urgent Care Service Claim – A claim involving an Urgent Care Service is processed as timely as is possible given the circumstances and will always be processed within no more than 48 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.),or, if shorter, the period of time required under Section 2719 of the federal Public Health Services Act and subsequent rules and regulations.
Initial Denial Notices
Notice of an Adverse Benefit Determination (including a partial claim denial) will be provided to You by mail,postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above. With respect to Adverse Benefit Determinations involving an Urgent Care Service, notice may be provided to You orally within the time frames noted above. If oral notice is given, written notification must be provided no later than three days after oral notification.
An Adverse Benefit Determination notice will identify the claim involved, convey the specific reason for the Adverse Benefit Determination (including the denial code and its meaning), the specific product provisions upon which We base the determination, and the contact information for the Ohio Department of Insurance, which is available to assist You with the internal and external appeal processes. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary. The notice will disclose if any internal product rule, protocol, or similar criterion was relied upon to deny the claim. A copy of the rule, protocol, or similar criterion will be provided to You, free of charge. In addition to the information provided in the notice, You have the right to request the diagnosis and treatment codes and descriptions upon which the determination is based.
The notice will describe Molina's review procedures and the time limits applicable to such procedures following an Adverse Benefit Determination on review.
If an Adverse Benefit Determination is based on Medical Necessity, Experimental or Investigational treatment or similar exclusion or limitation, the notice will provide an explanation of the scientific or clinical basis for the determination, free of charge. The explanation will apply the terms of the product to Your medical circumstances.
In the case of an Adverse Benefit Determination involving a claim for Urgent Care Service, the notice will provide a description of Molina’s expedited review procedures, which We describe below.
INTERNAL APPEALS
You must appeal an Adverse Benefit Determination within 180 days after receiving written notice of the denial (or partial denial). You may appeal an Adverse Benefit Determination by means of written notice to us, in person, orally, or by mail, postage prepaid.
Your request should include:
- The date of your request.
- Your name (please print or type).
- The date of the service we denied.
- Your identification number, claim number, and provider name as shown on the explanation of health care benefits, which You will automatically receive when we process Your claim.)
You should keep a copy of the request for Your records because no part of it can be returned to You.
You may request an expedited internal appeal of an Adverse Benefit Determination involving an Urgent Care Service orally or in writing. In such case,all necessary information will be transmitted between Molina and You by telephone,FAX, or other available similarly expeditious method, to the extent permitted by applicable law.
You may also request an expedited external review of an Adverse Benefit Determination involving an Urgent Care Service at the same time a request is made for an expedited internal appeal of an Adverse Benefit Determination if Your treating physician certifies that the Adverse Benefit Determination involves a medical condition that could seriously jeopardize Your life or health, or would jeopardize Your ability to regain maximum function,if treated after the time frame of an expedited internal appeal (i.e.,72-hours). You may not file a request for expedited external review unless You also file an expedited internal appeal. Determination of appeals of Adverse Benefit Determinations will be conducted promptly, will not defer to the initial determination, and will not be made by the person who made by the initial Adverse Benefit Determination or a subordinate of that person. The determination will take into account all comments, documents, records, and other information submitted by You relating to the claim.
On appeal, You may review relevant documents, request copies of any relevant information (which will be provided free of charge), and may submit issues and comments in writing. Upon request, You may also discover the identity of medical or vocational experts whose advice was obtained on behalf of Molina in connection with the Adverse Benefit Determination being appealed, as permitted under applicable law.
If We base the Adverse Benefit Determination in whole, or in part, upon a medical judgment, including determinations as to whether a particular treatment, drug, or other service is Experimental or Investigational, or not Medically Necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person.
If new or additional evidence is relied upon or if new or additional rationale is used during the internal appeal process, We will provide to You, free of charge, the evidence or rationale as soon as possible and in advance of the appeals decision in order to provide You a reasonable opportunity to respond. However,if We receive the new or additional evidence so late that it would be impossible to provide it to You in time for You to have a reasonable opportunity to respond, the period for providing notice of Our appeal decision will be tolled until You have a reasonable opportunity to respond. After You respond, or have a reasonable opportunity to respond but fail to do so, We will notify You of Our decision as soon as reasonably possible,considering the medical circumstances.
Your coverage will remain in effect pending the outcome of Your internal appeal.
Time Periods for Decisions on Appeal
For appeals of Adverse Benefit Determinations, We will make decisions and provide notice of the decisions as follows:
| TIMEFRAME FOR RESPONDING TO APPEAL |
| REQUEST TYPES |
TIMEFRAME FOR DECISION |
| URGENT CARE SERVICE DECISIONS |
WITHIN 48 HOURS from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
| PRE-SERVICE DECISIONS |
WITHIN 30 DAYS from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
| POST-SERVICE DECISIONS |
WITHIN 30 DAYS from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.) |
Urgent Care appeal or claims involving an Urgent Care Service is processed as timely as possible given the circumstances and will always be processed within no more than 48 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform you of the reason for denial.), or, if shorter, the period of time required under Section 2719 of the federal Public Health Services Act and subsequent rules and regulations.
Appeals Denial Notices
Notice of a Final Adverse Benefit Determination (including a partial denial) will be provided to You by mail, postage prepaid, by FAX or by e-mail, as appropriate,within the time periods noted above.
A notice that We have denied a claim appeal will include:
- Sufficient information to identify the claim involved;
- The specific reason or reasons for the Final Adverse Benefit Determination, including the denial code and its meaning;
- Reference to the specific product provision upon which the determination is based;
- A statement that You are entitled to receive, upon request and free of charge, reasonable access to, and copies of,all documents, records, and other information relevant to Your claim for benefits;
- If We relied upon any internal Molina rule, protocol or similar criterion to deny the claim, then a copy of the rule,protocol or similar criterion will be provided to You, free of charge, along with a discussion of Our decision;
- A statement of Your right to external review, a description of the external review process, and the forms for submitting an external review request, including release forms authorizing Molina to disclose protected health information pertinent to the external review; and
- If We base a Final Adverse Benefit Determination on Medical Necessity, Experimental or Investigational treatment or similar exclusion or limitation, the notice will provide an explanation of the scientific or clinical basis for the determination, free of charge. The explanation will apply the terms of this Agreement to Your medical circumstances.
- Notice of voluntary alternative dispute resolution options, as applicable
- For assistance with appeals, complaints or the external review process You may write or call:
Ohio Department of Insurance
Attn: Consumer Affairs
50 West Town Street
Suite 300
Columbus, OH 43215-1067
In addition to the information provided in the notice, You have the right to request the diagnosis and treatment codes and descriptions upon which the determination is based.
EXTERNAL REVIEW
Understanding the External Review Process
After You receive a Final Adverse Benefit Determination or if You are otherwise permitted, as described above, You may request an external review if You believe that a healthcare service has been improperly denied, modified, or delayed on the grounds that the healthcare service doesn’t meet Molina’s requirements for Medical Necessity, appropriateness, health care setting, level of care,effectiveness of a covered benefit, or is Experimental or Investigational.
Opportunity for External Review
An external review may be conducted by an Independent Review Organization (IRO) for Final Adverse Benefit Determinations involving Medical Necessity or medical judgment or by the Ohio Department of Insurance if the Final Adverse Benefit Determination involves a determination that the medical service is not covered by this Agreement. Molina will not choose or influence the IRO’s reviewers.
Your coverage will remain in effect pending the outcome of the external review.There are three types of IRO reviews:
- standard external review,
- expedited external review, and
- external review of Experimental or Investigational treatment.
Standard External Review
A standard external review is normally completed within 30 days
Expedited External Review
An expedited review for urgent medical situations, including reviews of Experimental or Investigational treatment involving an urgent medical situation are normally completed within 72 hours and can be requested if any of the following applies:
- Your treating physician certifies that the Adverse Benefit Determination or Final Adverse Benefit Determination involves a medical condition that could seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function if treatment is delayed until after the time frame of an expedited internal appeal or a standard external review.
- The Adverse Benefit Determination or Final Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care service for which You received Emergency Services,but have not yet been discharged from a facility
An expedited internal appeal is in process for an Adverse Benefit Determination of Experimental or Investigational treatment and Your treating physician certifies in writing that the recommended health care service or treatment would be significantly less effective if not promptly initiated External Review of Experimental and Investigational Treatment.
Requests for standard or expedited external reviews that involve Adverse Benefit Determinations or Final Adverse Benefit Determinations that a treatment is Experimental or Investigational may proceed if Your treating physician certifies one of the following:
- Standard health care services have not been effective in improving Your condition,
- Standard health care services are not medically appropriate for You, or
- No available standard health care service covered by Molina is more beneficial than the requested health care service
Request for External Review in General
- You must request an external review within 180 days of the date of the notice of Adverse Benefit Determination or Final Adverse Benefit Determination issued by Molina.
- All requests must be in writing, except for a request for an expedited external review.
- Expedited external reviews may be requested electronically or orally.
- If the request is complete, Molina will initiate the external review and notify You in writing that the request is complete and eligible for external review.
- The notice will include the name and contact information for the assigned IRO or the Ohio Department of Insurance (as applicable) for the purpose of submitting additional information
- The notice will inform You that, within 10 business days after receipt of the notice, You may submit additional information in writing to the IRO or the Ohio Department of Insurance (as applicable) for consideration in the review
- Molina will also forward all documents and information used to make the Adverse Benefit Determination to the assigned IRO or the Ohio Department of Insurance (as applicable).
- If the request is not complete Molina will inform You in writing and specify what information is needed to make the request complete.If Molina determines that the Adverse Benefit Determination is not eligible for external review, Molina will notify You in writing, and provide You with the reason for the denial, and inform You that the denial may be appealed to the Ohio Department of Insurance.
- The Ohio Department of Insurance may determine the request is eligible for external review regardless of the decision by Molina and require that the request be referred for external review. The Department’s decision will be made in accordance with the terms of the Molina and all applicable provisions of the law.
- Molina will pay the costs of the external review.
IRO Assignment
- The Ohio Department of Insurance maintains a secure web based system that is used to manage and monitor the external review process.
- When Molina initiates an external review by an IRO in this system, the Ohio Department of Insurance system randomly assigns the review to an Ohio accredited IRO that is qualified to conduct the review based on the type of health care service.
- Molina and the IRO are automatically notified of the assignment.
IRO Review and Decision
- The IRO must forward, upon receipt, any additional information it receives from You to Molina. At any time, Molina may reconsider its Adverse Benefit Determination and provide coverage for the health care service. Reconsideration will not delay or terminate the external review. If Molina reverses the Adverse Benefit Determination, We will notify You, the assigned IRO and the Ohio Department of Insurance within one day of the decision. Upon receipt of the notice of reversal by Molina,the IRO will terminate the review.
- In addition to all documents and information considered by Molina in making the Adverse Benefit Determination, the IRO must consider things such as; Your medical records, the attending health care professional’s recommendation, consulting reports from appropriate health care professionals, the terms of coverage under this Agreement and the most appropriate practice guidelines.
- The IRO will provide a written notice of its decision within 30 days of receipt by Molina of a request for a standard review or within 72 hours of receipt by Molina of a request for an expedited review. This notice will be sent to You, the Molina and the Ohio Department of Insurance and must include the following information.
- A general description of the reason for the request for external review
- The date the independent review organization was assigned by the Ohio Department of Insurance to conduct the external review
- The dates over which the external review was conducted
- The date on which the independent review organization’s decision was made
- The rationale for its decision
- References to the evidence or documentation, including any evidence-based standards,that was used or considered in reaching its decision
Binding Nature of External Review Decision
- An external review decision is binding on Molina except to the extent Molina has other remedies available under state law. The decision is also binding on You except to the extent that You have other remedies available under applicable state or federal law
- You may not file a subsequent request for an external review involving the same Adverse Benefit Determination that was previously reviewed unless new medical or scientific evidence is submitted to Molina
If you have questions about your rights or need assistance
You may contact:
Ohio Department of Insurance
ATTN: Consumer Affairs
50 West Town Street, Suite 300, Columbus, OH 43215
800-686-1526 / 614-644-2673
614-644-3744 (fax)
614-644-3745 (TDD)
Contact ODI Consumer Affairs:
https://www.insurance.ohio.gov/Consumer/Pages/ConsumerTab1.aspx
File a Consumer Complaint:
http://insurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx
DEPARTMENT OF INSURANCE EXTERNAL REVIEW
You may request an external review of a Final Adverse Benefit Determination by the Ohio Department of Insurance if you believe that a healthcare service has been improperly denied, modified, or delayed on the grounds that the healthcare service is not covered under this Agreement or You are denied an external review of an Adverse Benefit Determination or Final Adverse Benefit Determination.You may contact the Ohio Department of Insurance:
Ohio Department of Insurance
ATTN: External Review Unit
50 West Town Street, Suite 300, Columbus, OH 43215
800-686-1526 / 614-644-2673
614-644-3744 (fax)
614-644-3745 (TDD)
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