Complaints and Appeals

What is a Complaint?

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 in the manner described in the Internal Appeals section below. 

What if I Have a Complaint?

ifYou have a complaint, You can call the following toll-free number for assistance:

• Molina at 1 (855) 885-3176, Monday through Friday, 8:00 a.m. - 6:00 p.m. ET.
• If You are deaf or hard of hearing, You may contact Us by dialing 711 for the TTY Relay Service.
• You may also contact Molina through Our website www.MolinaMarketplace.com or by writing a letter. Our address is:

Molina Healthcare of South Carolina, Inc.
Grievance and Appeals Unit
PO Box 40309


North Charleston, SC 29423

• You may also contact the South Carolina Department of Insurance

Consumer Services Division
P.O. Box 100105
Columbia, SC 29202-3105
Phone: 1 (803) 737-6180 or 1 (800) 768-3467
Fax: 803-737-6231
E-mail: consumers@doi.sc.gov
Online complaint form: https://doi.sc.gov/consumers

Member Grievance/Appeal Request Form

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. Molina will provide written acknowledgement of Your complaint, and We will respond to Your complaint no later than 90 days from when We receive it. This period may be extended if there is a delay in obtaining the documents or records that are necessary to resolve Your complaint or if You and Molina agree in writing to extend the period.

Pending the resolution of Your complaint, Molina will not terminate Your coverage for any reason which is the subject of the complaint, except that Molina does have the right to terminate Your coverage where Molina has made a good faith, reasonable effort to resolve Your complaint and termination is otherwise permitted by the terms of this Agreement.

INTERNAL APPEALS AND EXTERNAL REVIEW

Definitions

For the purposes of this section:
“Adverse Benefit Determination” means a decision by Molina

1. To deny, reduce, fail to provide, or terminate a requested health care service or payment in whole or in part, due to any of the following:
   1. 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;
   2. A determination that a health care service is not a Covered Service;
   3. The imposition of an exclusion source of injury, network, or any other limitation on benefits that would otherwise be covered.
2. Not to issue individual health insurance coverage to an applicant, including initial eligibility determinations;
3. 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.
“Urgent Care Service” means a medical service where the application of non-Urgent Care Service time frames:

Could seriously jeopardize Your life, health, ability to regain maximum function, or Your unborn child; 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 claim.

Appointing a Representative

If You would like someone to act on Your behalf regarding a claim or an appeal of an Adverse Benefit Determination You may appoint an authorized representative. Please send Your representative’s name, address, and telephone contact information to:

Molina Healthcare of South Carolina, Inc.

Grievance and Appeals Unit
PO Box 40309
North Charleston, SC 29423
1 (855) 885-3176
711 (TTY)
Fax number: 1 (866) 713-1891

You must pay the cost of anyone You hire to represent or help You.

Throughout this “Internal Appeals and External Review” section, any reference to the term “You” and “Your” may include the person or entity who initiated the request (including Your authorized representative).

Initial Denial Notices

Notice of an Adverse Benefit Determination will be provided to You orally, by mail, postage prepaid, by FAX or by e-mail, as appropriate, within the time frames noted above.

An Adverse Benefit Determination notice will identify the claim or authorization request 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 South Carolina 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 or request, 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 or request. Upon request, 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 internal and external (standard and expedited) appeal procedures, the time limits applicable to such procedures following an Adverse Benefit Determination on review, and include the release form authorizing Molina to disclose protected health information pertinent to an external review. It will also include a description of the circumstances under which You don’t have to exhaust (complete) the internal process or the internal process may be deemed exhausted.

If an Adverse Benefit Determination is based on Medical Necessity, Experimental or Investigational treatment or similar exclusion or limitation, then upon request, Molina 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 an 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 or request number, and provider name as shown on the explanation of health care benefits, which You will automatically receive when We process Your claim or request.

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.

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 the initial Adverse Benefit Determination or a subordinate of that person. You also have the right to request that the person performing the review must practice the same profession as the attending health care provider. The determination will take into account all comments, documents, records, and other information submitted by You relating to the claim or request.

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:

TIME FRAME FOR RESPONDING TO APPEAL
REQUEST TYPES	TIME FRAME FOR DECISION
PRE-SERVICE APPEALS	We will notify You in writing of Our appeal decision as soon as practical, taking into account the medical circumstances, but not later than 30 calendar days after Our receipt of Your appeal.
POST-SERVICE APPEALS	We will notify You in writing of Our appeal decision as soon as practical, which generally will not be later than 30 calendar days after Our receipt of all information necessary to complete the appeal. However, in extraordinary circumstances, We will have up to 60 calendar days from the date that You submit Your appeal to provide You with notification of Our appeal decision.
EXPEDITED APPEALS (URGENT CARE SERVICE DECISIONS)	We will give You oral notice of Our appeal decision as soon as possible, considering the medical circumstances, but not later than either of the following timeframes: 2 business days of Our receipt of all information necessary to complete the appeal 72 hours from Our receipt of Your appeal

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 Final Adverse Benefit Determination will include:

Sufficient information to identify the claim or request 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 or request for benefits;
If We relied upon any internal Molina rule, protocol or similar criterion to deny the claim or request, 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 standard and expedited 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
The contact information for the director of the South Carolina Department of Insurance, which is available to assist with the internal and external appeal processes

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.

Exhaustion of the Internal Claims and Appeals Processes

A request for standard or expedited external review can’t be made until You have exhausted (completed) Our internal claims and appeals processes and received a Final Adverse Benefit Determination. However, in the following circumstances, You can request external review prior to exhausting Our internal processes:

Waiver:

Except in regards to post-service appeals, Molina can waive the exhaustion requirement, in which case You can request external review without exhausting Our internal processes.

Simultaneous Requests for Expedited Internal and External Reviews:

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.

Deemed Exhaustion:

If We do not adhere to the requirements outlined above, the internal claims and appeals processes may be deemed exhausted and You may have the right to request external review or other remedies under state law. If the internal processes are deemed exhausted, this is considered a Final Adverse Benefit Determination.

In order for the internal processes to be deemed exhausted, You need to request a written explanation from Us and we will respond in writing within 10 calendar days. The external reviewer or court will review Our explanation along with Your request and make a determination of whether the internal processes are exhausted. If Your request is rejected, We will notify You within 10 calendar days. You will have the right to resubmit and pursue an internal appeal of the Adverse Benefit Determination. Time periods for refiling will begin to run upon Your receipt of that notice. External Review

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.

An external review will be conducted by an Independent Review Organization (IRO).

Molina will not choose or influence the IRO’s reviewers.

There are three types of IRO reviews: 1) standard external review, 2) expedited external review, and 3) external review of Experimental or Investigational treatment.

Standard External Review

The IRO will provide You and Molina with written notice of its decision within 45 calendar days of its receipt of Your request for standard external review.

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

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, who must be a licensed physician qualified to practice in the area of medicine appropriate to treat Your condition, certifies:

You have a life-threatening disease or seriously disabling condition, and

Medical and scientific evidence, using accepted protocols, shows that the requested health care service is more beneficial to You than any standard health care service covered by Us, and the adverse risks of the requested health care service are not substantially greater than the standard health care service that is covered by Us, and

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 a standard external review within 4 months of the date of the notice of Adverse Benefit Determination or Final Adverse Benefit Determination issued by Molina. A request for an expedited external review has no filing deadline.

All requests must be in writing.

Molina will initiate the external review by notifying the South Carolina Department of Insurance of Your request, which will assign the IRO to conduct the external review. For standard external review requests, Molina will notify You in writing of the assignment to an IRO.

o The notice will include the name and contact information for the assigned IRO for the purpose of submitting additional information

oThe notice will inform You that, within 5 business days after receipt of the notice, You may submit additional information in writing to the IRO for consideration in the review

Molina will also forward all documents and information used to make the Adverse Benefit Determination or Final Adverse Benefit Determination to the assigned IRO.

If Molina determines that the Adverse Benefit Determination is not eligible for external review, Molina will notify You in writing within 5 business days of Our receipt of Your request for standard external review. For expedited requests, Molina will notify You as quickly as reasonably possible. The notice will provide You with the reason for the denial,  notify You of the director’s availability to provide assistance, and provide his phone number and address.

Molina will pay the costs of the external review.

IRO Assignment

When Molina initiates an external review, the South Carolina Department of Insurance will utilize an impartial and independent rotational system to assign the review to a South Carolina accredited IRO that is qualified to conduct the review based on the type of health care service. Molina will verify that no conflict of interest exists with the IRO.

IRO Review and Decision

Within 5 business days after the IRO’s receipt of Your request for standard external review, the IRO will determine whether Your request is eligible for external review and confirm that all information, forms and certifications were provided. The IRO will notify You immediately if additional information is required. If Your request is not accepted for standard  external review, the IRO will provide You and Molina with written notice explaining the reason. The IRO will notify You and Molina if Your request is accepted for standard external review. This paragraph does not apply to expedited external reviews.

If the IRO is reviewing an Adverse Benefit Determination or Final Adverse Benefit Determination involving an Experimental or Investigational treatment, the IRO will immediately select a clinical peer review panel to conduct the external review upon accepting Your request. The panel will be chosen by the IRO and will include experts on the treatment of Your condition and the requested health care service. Molina has the right to request that this panel include at least 3 health care professionals who meet these requirements. Each member of the panel will provide the IRO with a written opinion of whether to uphold or reverse Your Adverse Benefit Determination or Final Adverse Benefit Determination. The external review decision will be based on the recommendation of the majority of the clinical peer reviewers.

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 or Final 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 or Final Adverse Benefit Determination, We will notify You and the assigned IRO of that decision within 5 days for a standard review, and as quickly as reasonably possible for an expedited review.  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, the most appropriate practice guidelines, clinical review criteria developed by Molina, and any additional information or documents that were submitted by You. If the review is involving an Experimental or Investigational treatment, the IRO will consider whether the requested health care service is approved by the Federal Food and Drug Administration, or whether medical and scientific evidence demonstrate that the expected benefits of the requested health care service are greater than the benefits covered by Molina and the adverse risks of the requested health care service are not substantially greater than Molina’s covered services.

The IRO will provide You and Molina with written notice of its decision within 45 calendar days of its receipt of Your request for a standard review. The IRO will provide You and Molina with notice of an expedited review decision within 72 hours of receipt by Molina of a request for an expedited review. If the expedited review decision is not in writing, written notice will be provided within 48 hours of providing the oral notice.. The written notice will 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 South Carolina 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 principal reason for its decision
• 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
• The written opinions of the clinical peer review panel, if any

If the IRO reverses the Adverse Benefit Determination or Final Adverse Benefit Determination, We will approve a covered benefit that was the subject of a standard request within 5 business days of our receipt of the notice from the IRO, and as quickly as reasonable possible for an expedited request, subject to applicable exclusions, limitations, or other provisions of this Agreement.

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

If You Have Questions About Your Rights or Need Assistance with the Internal Claims and Appeals or External Review Processes

You may contact: 

South Carolina Department of Insurance
Consumer Services Division
P.O. Box 100105
Columbia, SC 29202-3105
Phone: 1 (803) 737-6180 or 1 (800) 768-346
Fax: 803-737-6231
E-mail: consumers@doi.sc.gov
Online complaint form: https://doi.sc.gov/consumers