Members

Grievance and Appeals

As a member, if you have a problem with your medical care or our services, you have a right to file a complaint (grievance) or appeal.
 
A complaint (grievance) can be filed when you are unhappy with your care.
Some examples are:
  • The care received from a provider;
  • The time it takes to get an appointment or be seen by a provider or;
  • The providers a member can choose for care.
 
An appeal can be filed when you do not agree with Molina Healthcare’s decision to:
  • Stop, suspend, reduce or deny a service or;
  • Deny payment for services provided.
 
To learn more, click on one of the links below:
 
Molina Healthcare wants you to have access to the complaint (grievance) process. We will provide you with help through each step. You can also get a summary of information about complaints or appeals that members have filed against the health plan.
 

What is a coverage decision?

A coverage decision is an initial decision we make about your benefits and coverage or about theamount we will pay for your medical services, items, or drugs. We are making a coverage decisionwhenever we decide what is covered for you and how much we pay.If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medicaid, eitherof you can ask for a coverage decision before the doctor gives the service, item, or drug. If you disagree with a coverage decision we have made, you can appeal our decision.

To ask for a coverage decision on medical services/items (Part C organization determination), or drugs (Part D coverage determination), call, write, or fax us, or ask your representative or doctor to ask us for a decision.

  • You can call us at: (877) 901-8181, TTY/TDD: 711, Monday - Friday, 8 a.m. to 8 p.m., local time
  • You can fax us at: (844) 251-1450
  • You can write to us at: Molina Dual Options, 1520 Kensington Road, Suite 212, Oak Brook, IL 60523

Call Member Services for ways you can ask us for a coverage decision on medical services/items (Part C organization determination), drugs (Part D coverage determination). You can also see Chapter 9 of the Member Handbook for more information.


*Printed copies of information posted on our website are available upon request.​​

You may have to pay for services that are not covered. You may also have to pay for services from providers not part of our network. If the services were an emergency, you don’t have to pay. If you need help, call Member Services.