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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
  • The providers a member can choose for care

 

An appeal can be filed when you do not agree with our decision to:

  • Stop, suspend, reduce or deny a service
  • Deny payment for services provided.

 

To learn more, click on one of the links below:

 

We want 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 the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever 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, either of 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: (855) 735-5831, TTY/TDD: 711, 7 days a week, 8 a.m. to 8 p.m., local time.
  • You can fax us at: (866) 423-3889
  • You can write to us at: Molina Dual Options Attn: Health Care Service Department P.O. Box 40309 North Charleston, SC 29423-0309

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.
 
 
 

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