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:
Call the California State Department of Managed Health Care (DHMC) toll-free at (888) HMO-2219 (888) 466-2219).
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 five (5) calendar days and will then issue a formal response within thirty (30) calendar days of the date of Your initial contact with us. All levels of grievances will be resolved within thirty (30) calendar days.
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 eighty (180) calendar days after the member’s receipt of the 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 eighty (180) calendar days after the member’s receipt of the Notice of Action (NOA).
We will send You a letter acknowledging receipt of Your appeal within five (5) calendar days. All levels of Molina Healthcare’s grievances and appeal procedures will be completed within thirty (30) calendar days.
You must file Your grievance within one hundred eighty (180) calendar days from the day the incident or action occurred which caused You to be unhappy.
If your grievance involves an imminent and serious threat to your health, Molina Healthcare 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 Managed Health Care. Molina Healthcare will issue a formal response no later than three (3) calendar days after your initial contact with us. You may also contact the Department of Managed Health Care immediately and are not required to participate in Molina Healthcare’s grievance process.
Department of Managed Health Care Assistance
The California Department of Managed Health Care 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 (888) 858-2150, 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 (888) 466-2219 and a toll-free TTD line ((877) 688-9891) for the hearing and speech impaired. The department’s Internet website http://www.hmohelp.ca.gov 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 Managed Health Care (“DMHC”) 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 IMR 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 IMR. You have the right to give information in support of the request for an IMR. Molina Healthcare 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 Molina Healthcare regarding the disputed health care service.
Eligibility for IMR: Your application for an IMR will be reviewed by the DMHC to co
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 thirty (30) calendar days. You are not required to wait for a response from Molina Healthcare for more than thirty (30) calendar days.
If Your grievance requires Expedited Review You may bring it immediately to the DMHC’s attention. You are not required to wait for response from Molina Healthcare for more than three (3) calendar days. The DMHC may waive the requirement that You follow Molina Healthcare’s grievance process in extraordinary and compelling cases.
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 assessment made in Your case. If the IMR determines the service is Medically Necessary, Molina Healthcare will provide the healthcare service.
For non-urgent cases, the IMR organization designated by the DMHC 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 three (3) calendar days.
For more information regarding the IMR process, or to request an application form, please call Molina Healthcare toll-free at (888) 858-2150. If You are deaf or hard of hearing, call our dedicated TTY line toll-free at (800) 735-2989, or call the California Relay Service at 711.
Independent Medical Review for Denials of Experimental/Investigational Therapies
You may also be entitled to an Independent Medical Review of our decision to deny coverage for treatment we have determined to be Experimental or Investigational.
The treatment must be for a life-threatening or seriously debilitating condition.
We will notify You in writing of the opportunity to request an Independent Medical Review of a decision denying an Experimental/ Investigational therapy within five (5) business days of the decision to deny coverage.
You are not required to participate in Molina Healthcare’s grievance process prior to seeking an Independent Medical Review of our decision to deny coverage of an Experimental/ Investigational therapy.
The Independent Medical Review will be completed within thirty (30) calendar days of the Department of Managed Health Care's receipt of Your application and supporting documentation. If Your doctor determines that the proposed therapy would be significantly less effective if not promptly initiated, the Independent Medical Review decision shall be rendered within seven (7) calendar days of the completed request for an expedited review.