This part explains what you can do if you have problems getting the medical care you believe we should provide. We use the word "provide" in a general way to include such things as authorizing care, paying for care, arranging for someone to provide care, or continuing to provide a medical treatment you have been getting. Problems getting the medical care you believe we should provide include the following situations:
If you are not getting the care you want, and you believe that this care is covered by Molina Dual Options.
If we will not authorize the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by Molina Dual Options. If you are being told that coverage for a treatment or service you have been getting will be reduced or stopped, and you feel that this could harm your health. If you have received care that you believe was covered by Molina Dual Options while you were a member, but we have refused to pay for this care.
Six possible steps for requesting care or payment from Molina Dual Options: If you are having a problem getting care or payment for care, there are six possible steps you can take to ask for the care or payment you want from us. At each step, your request is considered and a decision is made. If you are unhappy with the decision, you may be able to take another step if you want to continue requesting the care or payment.
In Steps 1 and 2, you make your request directly to us. We review it and give you our decision. In Steps 3 through 6, people in organizations that are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Dual Options program or the federal court system.
The six possible steps are summarized below (they are covered in more detail in the Member Handbook).
Step 1: The initial decision by Molina Dual Options
The starting point is when we make an "initial decision" (also called an "organization determination") about your medical care or about paying for care you have already received. When we make an "initial decision," we are giving our interpretation of how the benefits and services that are covered for members of Molina Dual Options apply to your specific situation. As explained in the Member Handbook, you can ask for a "fast initial decision" if you have a request for medical care that needs to be decided more quickly than the standard time frame.
Step 2: Appeal to Molina Dual Options
You may ask us to review our initial determination, even if only part of our decision is not what you requested. When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look.
Step 3: Review of your request by an Independent Review Organization
If we turn down part or all of your request in Step 2, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of Molina Dual Options. This organization will review your request and make a decision about whether we must give you the care or payment you want.
Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the independent review organization that reviews your case in Step 3, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your contested benefit must be at least $160 to be considered in Step 4.
Step 5: Review by a Dual Options Appeals Council
If you or we are unhappy with the decision made in Step 4, either of us may be able to ask a Dual Options Appeals Council to review your case. This Council is part of the federal department that runs the Dual Options program.
Step 6: Federal Court
If you or we are unhappy with the decision made by the Dual Options Appeals Council in Step 5, either of us may be able to take your case to a Federal Court. The dollar value of your contested medical care must at least $1630 to go to a Federal Court.
For a more detailed explanation of all six steps outlined above, see the Member Handbook.
How to ask for an Independent Medical Review
You can ask for an Independent Medical Review (IMR) for Medi-Cal covered services and items (not including In-Home Supportive Services). In most cases, you must file a Level 1 Appeal with Molina Dual Options Cal MediConnect before requesting an IMR. You cannot ask for an IMR if you have already had a State Fair Hearing on the same issue.
Step 1: You or your representative must ask for an IMR within 6 months after we send you a written decision. If you need help, you can call the Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891.
Step 2: Fill out the online Complaint/Independent Medical Review (IMR) Application Form available at http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.aspx or you can fill out the hrd copy IMR application form that is included with this notice and send it to:
Department of Managed Health Care
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
If you choose to do so, you may attach copies of letters or other documents about the service or item that was denied. If you do, send copies of documents, not originals. The Help Center cannot return any documents.
What happens next?
Doctors who are not part of Molina Dual Options Cal MediConnect will review your case. The Department of Managed Health Care will send you a letter explaining the decision. If you do not agree with the decision, you can ask for a State Fair Hearing.
How to ask for a State Fair Hearing
You have the right to ask for a State Fair Hearing for Medi-Cal covered services and items without asking us (health plan) to review our decision first. Please note that if you have had a State Fair Hearing, you will not be able to ask for an Independent Medical Review.
Step 1: You or your representative must ask for a State Fair Hearing within 90 days of the date of this notice. Fill out the "Form to File a State Hearing" that is included with this notice. Make sure you include all of the requested information.
Step 2: Send your completed form to:
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430
FAX: 916-651-5210 or 916-651-2789
You can also request a State Fair Hearing by calling 1-800-952-5253 (TDD: 1-800-952-8349).