How to Appeal a Denial

appeal

Appeals

If you receive a denial letter and do not like the choice we made, you can file an appeal. An appeal is a request to review a denial. The appeal must be about the following:

 

  • The care you want is denied.
  • The amount of care is decreased.
  • Your approved care was ended.
  • When payment for services is denied.
  • This may make you have to pay for the bill.

 

Filing an Appeal

All appeals must be filed in 30 days from the day of the denial. If you call, you will be asked to send more information in writing. You will need to send the letter in 10 days from your verbal appeal.

To file your appeal you can:

 

  • Call Member Services
  • Write a letter
  • Fill out the Grievance/Appeal form

 

Mail the letter or fax the form to:

Molina Healthcare of Florida, Inc.
Attention: Grievance & Appeals Department
P.O. Box 521838
Miami, FL 33152-1838
Phone: 1-866-472-4585
TTY/TDD: 1-800-955-8771
Fax: 1-877-508-5748
Email: MFLGrievanceandAppealsDepartment@MolinaHealthcare.Com

If you need a copy of the Grievance/Appeal Form you can call Member Services. We can help you write your appeal. Your request needs:

 

  • Your first and last name
  • Your signature
  • Date
  • Your Molina ID number. It is on the front of your Member ID Card
  • Your address and telephone number
  • Explain the problem

 

We try to solve your appeal right away. Your appeal is looked at by a Grievance and Appeals Coordinator. A letter is mailed to you, in 5 days. This letter lets you know we have your appeal. The coordinator will note and take care of your appeal. The coordinator will work with the right departments to solve your appeal. We will mail our decision in 30 days from the day we received it.

In order to be fair, cases will not be looked at by the same person that made the first decision. All appeals about medical services are reviewed by our medical staff.

Continuing benefits during appeal process

If you would like to go on with your benefits while you are appealing you must:

  1. Let us know in (10) days from the date on the denial letter.
  2. Let us know in (10) days after the effective date of the action, whichever is later.

 

The appeal must be about a service that was:

  1. Stopped
  2. Paused, or
  3. Reduction of a treatment that was approved before

 

The service must have been asked for by an approved doctor

  • The approval cannot have ended.
  • If you request an extension of benefits.

 

If we decide to go on with your benefits, your benefits will go on until:

  • You withdraw the appeal.
  • Ten days have passed from the date of the denial and you have not asked for a Medicaid Fair Hearing.
  • The Medicaid Fair hearing makes a decision not in your favor.
  • The authorization for the benefits has ended or the limits are met.

 

If you asked to go on with your benefits and the decision is not in your favor you may have to pay for the services that were given to you. Mail letter, call or fax the request to:

Molina Healthcare of Florida, Inc.
Attention: Grievance & Appeals Department
P.O. Box 521838
Miami, FL 33152-1838
Phone: 1-866-472-4585
TTY/TDD: 1-800-955-8771
Fax: 1-877-508-5748
Email: MFLGrievanceandAppealsDepartment@MolinaHealthcare.Com

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