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.