Appeal a Denial

denial

Appeal Process

You can file an appeal if Molina Healthcare denied, suspended, terminated, or reduced a requested service. This is called an adverse determination.
  • You have 90 days from the date of the adverse action notice to file an appeal.
  • You have the right to appeal orally or in writing to the Appeals Review Committee of Molina Healthcare. Molina Healthcare’s Appeal and Grievance Coordinator can help you write your appeal. If you would like to file an appeal, please call our Member Services Department at (888) 898-7969.
  • You have the right to include an authorized representative during the appeals process and to attend the Appeals Review Committee meeting. You must inform us of your authorized representative in writing. If your appeal is submitted by a representative but the authorization for the representative is not received in writing, the timeframe does not begin until after its receipt.
  • You can bring any information that you feel will help the Committee make a better decision.
  • The Coordinator will tell you the time and place the appeal will be held.
  • Molina Healthcare will use reviewers who were not involved in the initial decision to review. The reviewers are health care professionals who have the appropriate clinical expertise in treating your condition or disease. A decision will be mailed to you in 30 days from the date that Molina Healthcare received your appeal. Molina Healthcare will communicate to you in a way you will understand.
  • An additional 10 calendar days are allowed to obtain medical records or other important medical information if you request the extension, or if the Plan can demonstrate that the delay is in your best interest.
  • The Appeal and Grievance Coordinator will assist you in filing written appeals, including interpreter services if required. Oral interpretation is available for all languages. Hearing-impaired members are instructed to utilize the MI Relay line at 711 and “non- English” speaking members are assisted by our Bi-Lingual Representatives and Language Line services for all languages. Please call Member Services at ((888) 898-7969 for assistance.
  • Molina Healthcare will continue your benefits if all of the following conditions apply:
    • The appeal is filed timely, meaning on or before the later of within 10 days of Molina Healthcare mailing the notice of action or the intended effective date of the action
    • The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment
    • The services were ordered by an authorized doctor
    • The authorization period has not expired
    • You request an extension of benefits
  • If Molina Healthcare continues or reinstates your benefits while the appeal is pending, the benefits will be continued until one of the following occurs:
    • You cancel the appeal
    • You do not request a fair hearing within 10 days from when Molina Healthcare mails an adverse action notice
    • A State Fair Hearing decision adverse to you is made
    • The authorization expires or authorization limits are met
  • If Molina Healthcare reverses the adverse action decision or the decision is reversed by the State Fair Hearing, Molina Healthcare must pay for services provided while the appeal is pending and authorize or provide disputed services promptly, and as quickly as your health condition requires.
  • You may be required to pay the cost of the services if the denial is upheld.
  • Molina Healthcare will inform you of our decision in writing.