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Complaints and Appeals

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MEMBER GRIEVANCE AND APPEAL PROCEDURE
Molina Healthcare’s Grievance and Appeal Procedure is overseen by Our Grievance and Appeal Unit.Its purpose is to resolve issues and concerns from Members.We will provide You a written copy of Our grievance and appeal process upon request.We will never retaliate against a Member in any way for filing a grievance or appeal. For the purposes of this section, any reference to “You”, “Your” or “Member” also refers to a representative or health care provider designated by You to act on Your behalf, unless otherwise noted.

Summary of Health Insurance Grievance Procedures
This is a summary of the process You must follow when You request a review of a decision by Molina. You will be provided with detailed information and complaint forms by Us at each step. In addition, You can review the complete New Mexico regulations that control the process under the Legal tab on the Office of Superintendent of Insurance (OSI) website, located at www.osi.state.nm.us. You may also request a copy from Molina Healthcare of New Mexico, Inc. at: 1 (888) 295-7651 or from the OSI by calling 1-505-827-4601 or toll free at 1-855-427-5674.

What types of decisions can be reviewed?
You may request a review of two different types of decisions:

Adverse determination: You may request a review if Molina has denied a Prior Authorization for a proposed procedure, has denied full or partial payment for a procedure You have already received, or is denying or reducing further payment for an ongoing procedure that You are already receiving and that has been previously covered. (We must notify You before terminating or reducing coverage for an ongoing course of treatment, and must continue to cover the treatment during the appeal process.) This type of denial may also include a refusal to cover a service for which benefits might otherwise be provided because the service is determined to be Experimental or Investigational, or not Medically Necessary. It may also include a denial by the insurer of a participant’s or beneficiary’s eligibility to participate in a plan. These types of denials are collectively called “adverse determinations.”

Administrative decision: You may also request a review if you object to how Molina handles other matters, such as its administrative practices that affect the availability, delivery, or quality of health care services; claims payment, handling or reimbursement for health care services; or if Your coverage has been terminated.

Review of an Adverse Determination

How does Prior Authorization for a health care service work? When Molina receives a request for Prior Authorization of a healthcare service (service) or a request to reimburse Your healthcare provider (provider) for a service that You have already had, it follows a two-step process.

Coverage: First, We determine whether the requested service is a Covered Service under the terms of your Agreement. For example, if Your policy excludes payment for adult hearing aids, then your insurer will not agree to pay for you to have them even if you have a clear need for them.

Medical Necessity: Next, if Molina finds that the requested service is a Covered Service under Your Agreement, Molina determines, in consultation with a physician, whether a requested service is Medically Necessary. The consulting physician determines Medical Necessity either after consultation with specialists who are experts in the area or after application of uniform standards used by Molina. For example, if a person has a crippling hand injury that could be corrected by plastic surgery and that person is also requesting that an insurer pay for cosmetic plastic surgery to give them a more attractive nose, the insurer might certify the first request to repair the hand and deny the second, because it is not medically necessary.

Molina might also deny a Prior Authorization request if the service You are requesting is not a Covered Service. For example, if a policy does not pay for experimental procedures, and the service being requested is classified as experimental, the insurer may deny a request for authorization. Molina might also deny a Prior Authorization request if a procedure that Your provider has requested is not recognized as a standard treatment for the condition being treated.

IMPORTANT: If Molina determines that it will not provide an Authorization for Your request for services, You may still go forward with the treatment or procedure. However , You will be responsible for paying the provider yourself for the services.

How long does initial Authorization take?

Standard decision: Molina must make an initial decision within 5 working days. However, Molina may extend the review period for a maximum of 10 calendar days if it:
  1. can demonstrate reasonable cause beyond its control for the delay;
  2. can demonstrate that the delay will not result in increased medical risk to You; and
  3. provides a written progress report and explanation for the delay to You and Your provider within the original 5 working day review period.

What if I need services in a hurry?

Urgent care situation: An urgent care situation is a situation in which a decision from Molina is needed quickly because:
  1. delay would jeopardize Your life or health;
  2. delay would jeopardize Your ability to regain maximum function;
  3. the physician with knowledge of your medical condition reasonably requests an expedited decision;
  4. the physician with knowledge of Your medical condition, believes that delay would subject You to severe pain that cannot be adequately managed without the requested care or treatment; or
  5. the medical demands of Your case require an expedited decision.

If You are facing an urgent care situation or Molina has notified You that payment for an ongoing course of treatment that You are already receiving is being reduced or discontinued, You or Your provider may request an expedited review and Molina must either provide an Authorization or deny the initial request quickly. Molina must make its initial decision in accordance with the medical demands of the case, but within 24 hours after receiving the request for an expedited decision.

If You are dissatisfied with Molina’s initial expedited decision in an urgent care situation, you may then request an expedited review of Molina’s decision by both Molina and an external reviewer called an Independent Review Organization (IRO). When an expedited review is requested, We must review Our prior decision and respond to Your request within 72 hours. If You request that an IRO perform an expedited review simultaneously with Our review and your request is eligible for an IRO review, the IRO must also provide its expedited decision within 72 hours after receiving the necessary release of information and related records. If You are still dissatisfied after the IRO completes its review, You may request that the Superintendent review Your request. This review will be completed within 72 hours after Your request is complete.

The internal review, the IRO review, and the review by the Superintendent are described in greater detail in the following sections.


IMPORTANT: If You are facing an Emergency, You should seek medical care immediately and then notify Us as soon as possible. We will guide You through the claims process once the Emergency has passed.

When will I be notified that my initial request has been either Authorized or denied?
If the initial request is Authorized, Molina must notify You and Your provider within 1 working day after the decision, unless an urgent matter requires a quicker notice. If Molina denies the Authorization request, We must notify You and Your provider within 24 hours after the decision.

If my initial request is denied, how can I appeal this decision?
If Your initial request for services is denied or You are dissatisfied with the way We handle an administrative matter, You will receive a detailed written description of the grievance . procedures from Us as well as forms and detailed instructions for requesting a review. You must submit the request for review in writing, but assistance is available. Molina provides representatives who have been trained to assist You with the process of requesting a review. This person can help You to complete the necessary forms and with gathering information that You need to submit Your request. For assistance, contact Our Customer Support Center at:

Telephone: 1 (888) 295-7651
or if you are hard hearing you may contact our TTY at 1 (800) 659-8331
Address: PO Box 3887, Albuquerque, NM 87190

You may also contact the Managed Health Care Bureau (MHCB) at OSI for assistance with preparing the written request for a review at:

Telephone: 1-(505) 827-4601 or toll free at 1-(855) 427-5674
Address: Office of Superintendent of Insurance - MHCB
P.O. Box 1689, 1120 Paseo de Peralta
Santa Fe, NM 87504-1689
FAX #: (505) 827-6341, Attn: MHCB
E-mail: mhcb.grievance@state.nm.us

Who can request a review?
A review may be requested by You as the patient, Your provider, or someone that You select to act on Your behalf. The patient may be the Subscriber or a Dependent who receives coverage through the Subscriber. The person requesting the review is called the “grievant.”

Appealing an adverse determination – first level review
If You are dissatisfied with the initial decision by Us, You have the right to request that Our decision be reviewed by Our medical director. The medical director may make a decision based on the terms of this Agreement, may choose to contact a specialist or the provider who has requested the service on Your behalf, or may rely on Molina’s standards or generally recognized standards.

How much time do I have to decide whether to request a review?
You must notify Molina that You wish to request an internal review within 180 days after the date You are notified that the initial request has been denied.

What do I need to provide? What else can I provide?
If You request that Molina review its decision, We will provide You with a list of the documents that You need to provide and will provide to You all of Your records and other information the medical director will consider when reviewing Your case. You may also provide additional information that You would like to have the medical director consider, such as a statement or recommendation from Your doctor, a written statement from You, or published clinical studies that support Your request.

How long does a first level internal review take?
Expedited review. If a review request involves an urgent care situation, Molina must complete an expedited internal review as required by the medical demands of the case, but in no case later than 72 hours from the time the internal review request was received.

Standard review. Molina must complete both the medical director’s review and (if You then request it) Our internal panel review within 30 days after receipt of Your pre-service request for review or within 60 days if You have already received the service.. The medical director’s review generally takes only a few days.

The medical director denied my request - now what?
If You remain dissatisfied after the medical director’s review, You may either request a review by a panel that is selected by Molina or You may skip this step and ask that Your request be reviewed by an IRO that is appointed by the Superintendent.
  • If You ask to have Your request reviewed by Our panel, then You have the right to appear before the panel in person or by telephone or have someone, (including your attorney), appear with You or on Your behalf. You may submit information that You want the panel to consider, and ask questions of the panel members. Your medical provider may also address the panel or send a written statement.
  • If You decide to skip the panel review, You will have the opportunity to submit Your information for review by the IRO, but You will not be able to appear in person or by telephone. OSI can assist You in getting Your information to the IRO.

IMPORTANT: If you are covered under the NM State Healthcare Purchasing Act, you may NOT request an IRO review if you skip the panel review.
How long do I have to make my decision?
If You wish to have Your request reviewed by Molina’s panel, You must inform Us within 5 days after You receive the medical director’s decision. If You wish to skip Molina’s panel review and have Your matter go directly to the IRO, You must inform OSI of Your decision within 4 months after You receive the medical director’s decision.

What happens during a panel review?

If You request that We provide a panel to review Our decision, We will schedule a hearing with a group of medical and other professionals to review the request. If Your request was denied because We felt the requested services were not Medically Necessary, or were Experimental or Investigational, then the panel will include at least one specialist with specific training or experience with the requested services.


Molina will contact You with information about the panel’s hearing date so that You may arrange to attend in person or by telephone, or arrange to have someone attend with You or on Your behalf. You may review all of the information that We will provide to the panel and submit additional information that You want the panel to consider. If You attend the hearing in person or by telephone, You may ask questions of the panel members. Your medical provider may also attend in person or by telephone, and may address the panel or send a written statement.


Molina’s internal panel must complete its review within 30 days following Your original request for an internal review or within 60 days following Your original request if You have already received the services. You will be notified within 1 day after the panel decision. If You fail to provide records or other information that We need to complete the review, You will be given an opportunity to provide the missing items, but the review process may take much longer and You will be forced to wait for a decision.


Hint: If You need extra time to prepare for the panel’s review, then You may request that the panel be delayed for a maximum of 30 days.

If I choose to have my request reviewed by Molina’s panel, can I still request the IRO review?
Yes. If Your request has been reviewed by Molina’s panel and You are still dissatisfied with the decision, You will have 4 months to decide whether You want to request a review by the IRO.

What’s an IRO and what does it do?

An IRO is a certified organization appointed by OSI to review requests that have been denied by an insurer. The IRO employs various medical and other professionals from around the country to perform reviews. Once OSI selects and appoints an IRO, the IRO will assign one or more professionals who have specific credentials that qualify them to understand and evaluate the issues that are particular to a request. Depending on the type of issue, the IRO may assign a single reviewer to consider Your request, or it may assign a panel of reviewers. The IRO must assign reviewers who have no prior knowledge of the case and who have no close association with Molina or with You. The reviewer will consider all of the information that is provided by Us and by You. (OSI can assist You in getting Your information to the IRO.) In making a decision, the reviewer may also rely on other published materials, such as clinical studies.


The IRO will report the final decision to You, Your provider, Molina, and to OSI. We must comply with the decision of the IRO. If the IRO finds that the requested services should be provided, then We must provide them.


The IRO’s fees are billed directly to Us – there is no charge to You for this service.

How long does an IRO review take?
The IRO must complete the review and report back within 20 days after it receives the information necessary for the review. (However, if the IRO has been asked to provide an expedited review regarding an urgent care matter, the IRO must report back within 72 hours after receiving all of the information it needs to review the matter.)

Review by the Superintendent of Insurance

If You remain dissatisfied after the IRO’s review, You may still be able to have the matter reviewed by the Superintendent. You may submit your request directly to OSI, and if Your case meets certain requirements, a hearing will be scheduled. You will then have the right to submit additional information to support Your request and You may choose to attend the hearing and speak. You may also ask other persons to testify at the hearing. The Superintendent may appoint independent co-hearing officers to hear the matter and to provide a recommendation.


The co-hearing officers will provide a recommendation to the Superintendent within 30 days after the hearing is complete. The Superintendent will then issue a final order.


There is no charge to You for a review by the Superintendent of Insurance and any fees for the hearing officers are billed directly to Molina. However, if You arrange to be represented by an attorney or Your witnesses require a fee, You will need to pay those fees.


Review of an Administrative Decision

How long do I have to decide if I want to appeal and how do I start the process?
If You are dissatisfied with an initial administrative decision made by Molina, You have a right to request an internal review within 180 days after the date You are notified of the decision. We will notify you within 3 days after receiving Your request for a review and will review the matter promptly. You may submit relevant information to be considered by the reviewer.

How long does an internal review of an Administrative Decision take?
We will mail a decision to You within 30 days after receiving Your request for a review of an administrative decision.

Can I appeal the decision from the internal reviewer?
Yes. You have 20 days to request that Molina form a committee to reconsider Our administrative decision.

What does the reconsideration committee do? How long does it take?
When Molina receives Your request, it will appoint two or more members to form a committee to review the administrative decision. The committee members must be representatives of Molina who were not involved in either the initial decision or the internal review. The committee will meet to review the decision within 15 days after Molina receives Your request. You will be notified at least 5 days prior to the committee meeting so that You may provide information, and/or attend the hearing in person or by telephone.
If You are unable to prepare for the committee hearing within the time set by Us, You may request that the committee hearing be postponed for up to 30 days. The reconsideration committee will mail its decision to You within 7 days after the hearing.

How can I request an external review?
If You are dissatisfied with the reconsideration committee’s decision, You may ask the Superintendent to review the matter within 20 days after You receive the written decision from Molina. You may submit the request to OSI using forms that are provided by Us. Forms are also available on the OSI website located at www.osi.state.nm.us. You may also call OSI to request the forms at (505) 827-4601 or toll free at 1-(855)-427-5674.

How does the external review work?
Upon receipt of Your request, the Superintendent will request that both You and Molina submit information for consideration. Molina has 5 days to provide Our information to the Superintendent, with a copy to You. You may also submit additional information including documents and reports for review by the Superintendent. The Superintendent will review all of the information received from both You and Molina and issue a final decision within 45 days. If You need extra time to gather information, You may request an extension of up to 90 days. Any extension will cause the review process and decision to take more time.


General Information

Confidentiality
Any person who comes into contact with Your personal health care records during the grievance process must protect Your records in compliance with state and federal patient confidentiality laws and regulations. In fact, the provider and Molina cannot release Your records, even to OSI, until You have signed a release.

Special needs and cultural and linguistic diversity
Information about the grievance procedures will be provided in accessible means or in a different language upon request in accordance with applicable state and federal laws and regulations.

Reporting requirements
Insurers are required to provide an annual report to the Superintendent with details about the number of grievances it received, how many were resolved and at what stage in the process they were resolved. You may review the results of the annual reports on the OSI website.


The preceding summary has been provided by the Office of Superintendent of Insurance. This is not legal advice, and You may have other legal rights that are not discussed in these procedures

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