How to Appeal a Denial

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. For more information, you can call Member Services.

See the Member Handbook for detailed information about how to make an appeal that involves a request for Part D drug benefits.

This section gives the rules for making appeals and/or complaints in different types of situations. Federal law guarantees your right to make appeals and complaints if you have concerns or problems with any part of your medical care as a plan member. The Molina Dual Options program has helped set the rules about what you need to do to make an appeal and/or complaint and what we are required to do when we receive an appeal and/or complaint. If you make an appeal and/or complaint, we must be fair in how we handle it. You cannot be disenrolled from Molina Dual Options or penalized in any way if you make an appeal and/or complaint.

What are appeals and complaints?

You have the right to make an appeal and/or complaint if you have concerns or problems related to your coverage or care.

  • An "appeal" is when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Molina Dual Options or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Molina Dual Options or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal.
  • A "grievance" is the type of complaint you make if you have any other type of problem with Molina Dual Options or one of our plan providers. For example, you would file a complaint if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office.


To obtain information on the process or status, or on the number of appeals, complaints, and exceptions filed with Molina Dual Options please Contact Member Services.

  • Part 5. Complaints (grievances) about any other type of problem you have with Molina Dual Options or one of our plan providers

    In the Member Handbook, How to File a Grievance, explains how to make complaints about any other type of problem that has not already been discussed above. (The problems that have already been discussed are problems related to coverage or payment for care or Part D benefits, problems about being discharged from the hospital too soon, and problems about coverage for SNF, HHA, or CORF services ending to soon.)

    What is included in "all other types of problems"?

    Here are some examples of problems that are included in this category of "all other types of problems":

    - Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
    - If you feel that you are being encouraged to leave (disenroll from) Molina Dual Options.
    - Problems with the Member Service you receive.
    - Problems with how long you have to spend waiting on the phone, in the waiting room, or in the exam room.
    - Problems with getting appointments when you need them, or having to wait a long time for an appointment.
    - Disrespectful or rude behavior by doctors, nurses, receptionists, or other staff.
    - Cleanliness or condition of doctor's offices, clinics, or hospitals.
    - If you have one of these types of problems and want to make a complaint, it is called "filing a grievance." In addition, you have the right to ask for a "fast grievance" if you disagree with our decision to not give you a "fast appeal" or if we take an extension on our initial decision or appeal. See below for more detail.

    Filing a complaint with Molina Dual Options

    If you have a complaint, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Member Grievance Process.

    You must file your complaint within 60 days of the event that gives rise to the complaint. You may file a complaint either orally or in writing, by one of the methods below.

    Contact Member Services:
    (855) 735-5831
    8:00 a.m. - 8:00 p.m. Monday to Sunday
    TTY/TDD 711 This number requires special telephone equipment. Calls to this number are free.

    FAX (866) 771-0117

    Molina Healthcare
    ATTN: Grievance and Appeals Department
    PO Box 22816
    Long Beach, CA 90801-9977

    We will respond to all written complaint in writing. We will respond to oral complaint orally, unless you specifically request a written response. We will respond to all quality of care complaints in writing, regardless of how the complaint was filed.

    Expedited Grievance/Complaint Procedure:

    You (or your representative, with appropriate authorization) are entitled to a fast complaint. The legal term for "fast complaint" is "expedited grievance."

    - If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast complaint" and respond to your complaint within 24 hours.
    - If you are making a complaint because we took extra time to make a coverage decision or appeal, we will automatically give you a "fast complaint" and respond to your complaint within 24 hours.

    If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.

    Standard Grievance/Complaint Procedure:

    For all other grievances, we will make a decision and notify you of our decision as your case requires based on your health status, but not later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

    For quality of care problems, you may also complain to the QIO.

    If you are unhappy with the quality of care, such as the care you got in the hospital, you can make a complaint with the QIO. See the Member Handbook for more information about the QIO.

* Member Handbook: Links in this section go to the Member Handbook.

Molina Dual Options is an organization with a Dual Options contract. This contract is renewed annually, and coverage beyond the end of the current benefit year is not guaranteed.