How to Appeal a Denial
You have the right to appeal a denial
What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be rendered or bills will not be paid. If we deny your service or claim, you have the right to request why your services or bills were denied. You also have the right to appeal.
If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. This denial letter will tell you about your right to appeal. You can also read about these rights in your Member Handbook.
How to appeal a denial
If you receive a denial letter from Molina Healthcare, there are three steps in the appeal process:
STEP 1: Molina Healthcare Appeal
STEP 2: Independent Review
STEP 3: State Hearing
If you need help filing an appeal, call Member Services at (855) 766-5462. Within 3 business days, we will let you know in writing that we got your appeal. You may choose someone, including an attorney or provider, to represent you and act on your behalf. You must sign a consent form allowing this person to represent you. Molina Healthcare does not cover any fees or payments to your representatives. That is your responsibility.
You have 60 calendar days after the date of Molina Healthcare’s denial letter to ask for an appeal. You or your representative may submit information about your case in person or in writing. If you want copies of the guidelines we used to make our decision, we can give them to you free of charge. We will keep your appeal private. We will send you our decision in writing within 15 business days from the date you contacted us, unless we tell you we need more time. Molina Healthcare may request an extension up to 14 more calendar days to make a decision on your case if we need to get more information before we make a decision.
Continuation of Services During the Appeal Process
If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process.
Expedited (Faster) Decisions
If you or your provider think waiting for a decision would put your health at risk, ask for an expedited (faster) appeal or state hearing. We will review your request and make a decision within 24 hours. If we decide your health is not at risk, we will follow the regular appeal process time to make our decision.