Molinalogo

What is an Appeal?

If you receive a Notice of Adverse Benefit Determination(“NOABD”)(denial letter) informing you of a denial or other adverse benefit determination (a decision not made in your favor) and do not agree with our decision, you may file an appeal.

An appeal is a request to review an adverse benefit determination (a decision not made in your favor) or denial. An adverse benefit determination (a decision not made in your favor) is:

• Limiting or denying services;
• Reducing services;
• Suspending services;
• Terminating services;
• Denying payment for services;
• Failing to provide services in a timely manner;
• Failing to resolve appeals and grievances within timeliness guidelines;
• For a resident of a rural area with only one (1) MCO in the area, the denial of a request to exercise his or her right to get services outside the Molina network; or
• The denial of a request to dispute a financial responsibility, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial responsibilities.

If your appeal is about a service that was already authorized, you may be able to keep getting the service while we review your appeal.

You or your authorized representative may ask for copies of any documents used to review your appeal free of charge before a decision is made by Molina. This may include medical records, other documents and records, and any new or additional information.

Standard Appeals

We will resolve your standard appeal as quickly as possible, but no later than thirty (30) calendar days from the date your appeal was received.

You can ask Molina to extend the timeframe to resolve your appeal by up to fourteen (14) calendar days. Molina can also extend the timeframe to resolve your appeal by up to fourteen (14) calendar days if Molina thinks the delay is in your best interest. If Molina extends the timeframe, we must be able to explain to the South Carolina Department of Health and Human Services (SCDHHS) how the delay is in your best interest. We will call you and a letter will be sent to you informing you of the extension and why the delay is in your best interest. If Molina extends the timeframe, the letter will also include information about your right to file a grievance about extending the timeframe.

Expedited Appeals

If you or your doctor think waiting up to thirty (30) calendar days for a standard appeal is too long and would be life-threatening, could hurt your health or ability to get, maintain, or regain maximum function, you may request an expedited (fast) appeal.

We will determine if your request meets the expedited appeal criteria within twenty-four (24) hours of your appeal request. If it meets the expedited appeal criteria, we will let you know of the limited time available to send us additional information for the appeal. We will make a decision as quickly as possible, but no later than seventy-two (72) hours from when we received your appeal.

You can ask Molina to extend the timeframe to resolve your appeal by up to fourteen (14) calendar days. Molina can also extend the timeframe to resolve your appeal by up to fourteen (14) calendar days if Molina thinks that the delay is in your best interest. If Molina extends the timeframe, we must be able to explain to SCDHHS how the delay is in your best interest. We will call you, and a letter will be sent to you informing you of the extension and why the delay is in your best interest. If Molina extends the timeframe, the letter will also include information about your right to file a grievance about extending the timeframe.

If the request does not meet the expedited appeal criteria, we will let you know in writing, and it will be resolved within the standard thirty (30) calendar days. You may file a grievance with us if you are unhappy about the decision not to handle your appeal as expedited.

How to File an Appeal

You or your authorized representative (this can be a friend, family member, attorney or a provider) may file an appeal orally or in writing within sixty (60) calendar days from the date on the Notice of Adverse Benefit Determination (“NOABD”) (denial letter). Providers and other authorized representatives must have your written consent to file an appeal on your behalf. A provider can appeal on your behalf if you have agreed to treatment, Molina has received medical records from the provider, and/or there is a history of paid claims for services from the provider.

To file your appeal, you can:

Mail the letter or form to:

You can also fax the letter or form to (877) 823-5961, Attn: Molina Appeals and Grievances.

You can choose someone else to file an appeal for you. Molina needs your permission in writing for someone else to file an appeal for you.

If you are sending us a letter about your appeal or completing the form, you should include:

• Date
• Your first and last name
• Your address and telephone number
• Your email address
• Your Molina Member ID number, which is on the front of your Member ID Card
• Description of the issue
• Your signature

You should also attach any medical information that will help us to understand your medical condition and your appeal. This information can be sent to us in writing, or you can bring it to our office in person.

Member Appeal Handling

We will try to solve your appeal right away. A letter will be mailed to you within five (5) business days of when we receive your appeal to let you know we have your appeal.

For standard appeal decisions, we will send you a letter with our decision within thirty (30) calendar days from the day we received it. If we need more time, or you need more time, we can extend the thirty (30) calendar days by fourteen (14) more calendar days.

For expedited appeal decisions, we will call you and send you a letter with our decision within seventy-two (72) hours of when we received the request. If we need more time, or you need more time, we can extend the seventy-two (72) hours by fourteen (14) more calendar days.

Cases will not be looked at by the same person that made the first decision. All appeals about medical services are reviewed by our medical staff.