When you are a patient in a SNF, Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), you have the right to get all the SNF, HHA or CORF care covered by Molina Dual Options that is necessary to diagnose and treat your illness or injury. The day we end your SNF, HHA or CORF coverage is based on when your stay is no longer medically necessary. This part explains what to do if you believe that your coverage is ending too soon.
Information you will receive during your SNF, HHA or CORF stay
If we decide to end our coverage for your SNF, HHA, or CORF services, you will get written notice either from us or your provider at least 2 calendar days before your coverage ends. You (or someone you authorize) will be asked to sign and date this document to show that you received the notice. Signing the notice does not mean that you agree that coverage should end - it only means that you received the notice.
How to get a review of your coverage by the Quality Improvement Organization
You have the right by law to ask for an appeal of our termination of your coverage. As will be explained in the notice you get from us or your provider, you can ask the Quality Improvement Organization (the "QIO") to do an independent review of whether our terminating your coverage is medically appropriate.
How soon you have to ask the QIO to review your coverage?
If you want to have the termination of your coverage appealed, you must act quickly to contact the QIO. The written notice you got from us or your provider gives the name and telephone number of your QIO and tells you what you must do.
If you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.
If you get the notice and you have more than 2 days before your coverage ends, then you must make your request no later than noon of the day before the date that your Dual Options coverage ends.
What will happen during the review?
If the QIO reviews your case, the QIO will ask for your opinion about why you believe the services should continue. You do not have to prepare anything in writing, but you may do so if you wish. The QIO will also look at your medical information, talk to your doctor, and review other information that we have given to the QIO. You and the QIO will each get a copy of our explanation about why your services should not continue.
After reviewing all the information, the QIO will give an opinion about whether it is medically appropriate for your coverage to be terminated on the date that has been set for you. The QIO will make this decision within one full day after it receives the information it needs to make a decision.
What happens if the QIO decides in your favor?
If the QIO agrees with you, then we will continue to cover your SNF, HHA or CORF services for as long as medically necessary.
What happens if the QIO denies your request?
If the QIO decides that our decision to terminate coverage was medically appropriate, you will be responsible for paying the SNF, HHA or CORF charges after the termination date on the advance notice you got from us or your provider. Neither Original Dual Options nor Molina Dual Options will pay for these services. If you stop receiving services on or before the date given on the notice, you can avoid any financial liability.
What if you do not ask the QIO for a review in time?
You still have another option: asking Molina Dual Options for a "fast appeal" of your discharge.
If you do not ask the QIO for a "fast appeal" of your discharge by the deadline, you can ask us for a "fast appeal" of your discharge. How to ask us for a fast appeal is covered briefly in the first part of this section and in more detail in the Member Handbook.
If you ask us for a fast appeal of your termination and you continue getting services from the SNF, HHA, or CORF, you run the risk of having to pay for the care you receive past your termination date. Whether you have to pay or not depends on the decision we make.
If we decide, based on the fast appeal, that you need to continue to get your services covered, then we will continue to cover your care for as long as medically necessary.
If we decide that you should not have continued getting coverage for your care, then we will not cover any care you received if you stayed after the termination date. You may have to pay if you stay past your discharge date.
If you do not ask the QIO by noon after the day you are given written notice that we will be terminating coverage for your SNF, HHA or CORF services, and if you stay in the SNF, HHA or CORF after this date, you run the risk of having to pay for the SNF, HHA or CORF care you receive on and after this date. However, you can appeal any bills for SNF, HHA or CORF care you receive using Step 1 of the appeals process described in the Member Handbook.