You Can File an Appeal
What is an Appeal?
If you do not agree with Molina's choice to deny a requested service(s), and you ask that we change our decision - this is an appeal. To make an appeal, you must contact Molina within 60 calendar days of the denial.
You, your approved representative (this can be a friend, family member, attorney), or a provider can file an appeal by phone or in writing. This must be done within 60 calendar days from the date on the Notice of Adverse Benefit Determination Letter (“NOABD”) (denial letter) you got in the mail. This letter told you about the denial or other adverse benefit determination (a decision not made in your favor).
You can call us at (855) 882-3901 to file your appeal, or you can send your appeal in writing. To send us an appeal in writing, mail the document to:
Molina Healthcare of South Carolina
Chattanooga, TN 37422
If you want to file an appeal in person, you may come to the Molina office. The address is 115 Fairchild Street, Suite 340, Daniel Island, SC 29492. Please call Molina at (855) 882-3901 to make an appointment.
Providers and other approved representatives must have your written approval to file an appeal for you. A provider can appeal for you if:
• You agreed to treatment,
• Molina received medical records from the provider, and/or
• Here is a history of paid claims for services from the provider.
When you file an appeal, you can send us any information you have that will help us decide. We will send you a letter letting you know we received your appeal within five business days of receiving your request. While your appeal is being reviewed, you can send or deliver any other information you think will help us make our decision.
When reviewing your appeal, we will:
• Use doctors who know about the type of illness you have.
• Not use the same doctors or medical people who denied your request for a service.
• Make a decision about your appeal within 30 calendar days of receipt of your request for an appeal.
• Resolve your standard appeal as quickly as possible, but no later than 30 calendar days from the day Molina receives your appeal.
You can ask Molina to extend the time to resolve your appeal by up to 14 calendar days. Molina can also extend the time to resolve your appeal by up to 14 calendar days if Molina thinks the delay is good for you. If Molina extends the time, we must be able to tell SCDHHS how the delay is best for you. We will call you, and send you a letter that tells you about the delay and why it is best for you. If Molina extends the time, the letter will also tell you about your right to file a grievance.
You or your approved representative can ask for copies of any documents used to review your appeal before Molina decides. This may include medical records, other documents, and records, and any new or additional information. Please contact Member Services if you need a copy Molina will not charge you for these documents.
You can request an expedited (fast) appeal if you or your doctor think waiting up to 30 calendar days for a standard appeal is too long because it:
• Could be life-threatening.
• Could hurt your health.
• Could hurt your ability to get, maintain, or regain maximum function.
We will decide if your request meets the expedited appeal criteria within 24-hours of your appeal request. If it meets the criteria, we will let you know how much time you have to send Molina additional information for the appeal. We will decide as quickly as possible, but no later than 72 hours from the day we receive your request.
If it does not meet the criteria for an expedited appeal, we will let you know in writing and resolve it within the standard 30 calendar days. You may file a grievance with us if you are unhappy about the decision not to handle your appeal as expedited.
You can ask Molina to extend the time to resolve your appeal by up to 14 calendar days. Molina can also extend the time to resolve your appeal by up to 14 calendar days if Molina thinks that the delay is best for you. If Molina extends the time, we must be able to tell SCDHHS how the delay is best for you. We will call you and mail you a letter that tells you about the extension and why the delay is best for you. If Molina extends the time, the letter will also include information about your right to file a grievance for extending the time.
If your appeal is about a service that was already approved and you were already receiving, you may be able to keep getting the service while we review your appeal. Contact us at (855) 882-3901 if you want to keep getting services while your appeal is being reviewed.
Once we complete our review, we will send you a certified letter letting you know our decision. If we decide you should not receive the denied service, that letter will tell you how to ask for a State Fair Hearing.
Continuing Your Benefits
If your appeal is about services that were already approved, you may be able to keep getting those services during the appeal process. You must make a request within ten calendar days from the date on your Notice of Adverse Benefit Determination Letter (“NOABD”) (denial letter) to keep getting services. If your appeal is denied, you may have to pay for the services you received while the appeal was being reviewed.
Requesting a Copy of the Appeal File
If at any time during this process, you want to see the Molina case file or see any documents related to your appeal, you may request this. Molina will provide these items to you.
State Fair Hearing
If we review your appeal request and still deny the services you asked for, we will tell you by certified mail. You must sign a receipt showing you received the letter.
If you are not happy with the appeal decision, you can ask for a State Fair Hearing. You may request a State Fair Hearing within 120 calendar days of the date on the notice of appeal resolution letter telling you our decision. You must finish Molina’s internal appeals process before asking for a State Fair Hearing. Molina will be at the State Fair Hearing along with you and your representative. Molina cannot represent you at a State Fair Hearing. Molina can help you find a legal representative if you need one.
If your State Fair Hearing is about a service that was already approved and you were already receiving, you may be able to keep getting the service while your Hearing is pending. Contact Molina at (855) 882-3901 if you want to keep getting services while your Hearing is pending. If the Hearing is not decided in your favor, you may have to pay for the services you received while the Hearing is pending. If you choose to disenroll from Molina and SCDHHS does not approve it, you may request a State Fair Hearing. Please call Member Services if you need help requesting a State Fair Hearing.
To request a State Hearing, you must send the request in writing to:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings
1801 Main Street
PO Box 8206
Columbia, SC 29202
Phone Number: (803) 898-2600
Toll-Free Number: (800) 763-9087
Fax Number: (803) 255-8206