As a Molina Healthcare member, if you have a problem with your medical care or our
services, you have a right to file a complaint (grievance) or appeal. Some examples
- The care you get from your provider.
- The time it takes to get an appointment or be seen by a provider.
- The providers you can choose for care.
An appeal can be filed when you do not agree with Molina Healthcare’s decision to:
- Stop, change, suspend, reduce or deny a service.
- Deny payment for services provided.
What if I Have a Complaint?
If You have a problem with any Molina Healthcare services, we want to help fix it.
You can call any of the following toll-free for help:
- Call Molina Healthcare toll-free at (888) 560-2025. We are here Monday
through Friday, 8:00 a.m. - 6:00 p.m. CDT. Deaf or hard of hearing Members may call
our toll-free TTY number at 1 (800) 735-2989. You may also contact us by calling
the National Relay Service at 711.
- You may also send us Your problem or complaint in writing by mail or filing online
at our website. Our address is:
Molina Healthcare of Texas
Attn: Member Complaints & Appeals
P.O. Box 165089
Irving, TX 75016
Member Grievance/Appeal Request Form
Molina Healthcare recognizes the fact that Members may not always be satisfied with
the care and services provided by our contracted doctors, hospitals and other providers.
We want to know about Your problems and complaints. You may file a grievance (also
called a complaint) in person, in writing, or by telephone as described above. Molina
Healthcare also will provide oral language services that includes answering questions
in any applicable non-English language and providing assistance with filing claims
and appeals (including external review) in any applicable non-English language.
You can request that any notice from Molina Healthcare be provided in any applicable
non-English language. With respect to any Texas county to which a notice is sent,
a non-English language is an applicable non-English language if ten percent (10%)
or more of the population residing in the county is literate only in the same non-English
language as determined by the Department of Health and Human Services (HHS).
Complaints - We will send You a letter acknowledging receipt of Your grievance
within 5 days of receipt of the complaint. Grievances will be resolved within thirty
(30) calendar days from receipt of the complaint. A complaint or grievance concerning
disagreement or dissatisfaction with an Adverse Benefit Determination constitutes
an appeal of that Adverse Benefit Determination. Appeals of Adverse Benefit Determinations
will be resolved as noted below.
Appealing Resolution of Complaints – If You are not satisfied with the resolution
of Your complaint, You may appeal that resolution in writing. You may request to
appear in person before a complaint appeal panel or address a written appeal to
the complaint appeal panel. If You appeal the resolution of a Complaint, We will
send an acknowledgment letter to You no later than the fifth business day after
We receive Your written request for appeal. We will complete the appeals process
no later than the 30th calendar day after the date the written request for appeal
If you appeal Your complaint resolution, We will appoint members to a complaint
appeal panel to advise us on the resolution of a disputed decision appealed.
The complaint appeal panel will be composed of an equal number of Molina staff members,
physicians or other providers, and enrollees. A member of a complaint appeal panel
may not have been previously involved in the disputed decision. The physicians or
other providers on a complaint appeal panel will have experience in the area of
care that is in dispute and must be independent of any physician or provider who
made any previous determination. If specialty care is in dispute, the complaint
appeal panel will include a person who is a specialist in the field of care to which
the appeal relates. The enrollee members of a complaint appeal panel will not be
employees of Molina.
Adverse Benefit Determinations
An "Adverse Benefit Determination" means a determination by Molina
Healthcare that health care services provided or proposed to be provided to a Member
are not Medically Necessary or are Experimental or Investigational. A rescission
of coverage is also an Adverse Benefit Determination. A rescission does not include
a termination of coverage for reasons related to non—payment of premium.
Molina shall provide notice of an adverse determination as follows:
(1) with respect to a patient who is hospitalized at the time of the adverse determination,
within one working day by either telephone or electronic transmission to the provider
of record, followed by a letter within three working days notifying the patient
and the provider of record of the adverse determination;
(2) with respect to a patient who is not hospitalized at the time of the adverse
determination, within three working days in writing to the provider of record and
the patient; or
(3) within the time appropriate to the circumstances relating to the delivery of
the services to the patient and to the patient's condition, provided that when
denying post stabilization care subsequent to emergency treatment as requested by
a treating physician or other health care provider, the agent shall provide the
notice to the treating physician or other health care provider not later than one
hour after the time of the request.
The notice of an adverse determination will include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description of or the source of the screening criteria used as guidelines
in making the adverse determination;
(4) the professional specialty of the physician, doctor, or other health care provider
that made the adverse determination;
(5) a description of the procedure for the URA's complaint system as required
by §19.1705 of this title (relating to General Standards of Utilization Review);
(6) a description of the URA's appeal process, as required by §19.1711 of this
title (relating to Written Procedures for Appeal of Adverse Determination);
(7) a copy of the request for a review by an IRO form, available at www.tdi.texas.gov/forms;
(8) notice of the independent review process with instructions that:
- (A) request for a review
by an IRO form must be completed by the enrollee, an individual acting on behalf
of the enrollee, or the enrollee's provider of record and be returned to the
insurance carrier or URA that made the adverse determination to begin the independent
review process; and
- (B) the release of medical
information to the IRO, which is included as part of the independent review request
for a review by an IRO form, must be signed by the enrollee or the enrollee's
legal guardian; and
(9) a description of the enrollee's right to an immediate review by an IRO and
of the procedures to obtain that review for an enrollee who has a life-threatening
condition. If the denial involves a life-threatening condition, the notice will
also include a description of Your right to an immediate review by an independent
review organization and of the procedures to obtain that review.
In the case of an adverse determination resulting from a retrospective review Molina
will provide written notice to the member, within 30 days after the claim is received.
You may request an Appeal of an Adverse Benefit Determination
Appeal Procedures for Adverse Benefit Determinations (Including Expedited Clinical
Expedited Clinical Appeals
If Your situation meets the definition of an expedited clinical appeal, You may
be entitled to an appeal on an expedited basis. An "expedited clinical appeal"
is an appeal of a clinically urgent nature related to health care services, including
but not limited to, Prior Authorization for treatment, denial of emergency care
or concurrent or continued hospitalization. Before authorization of benefits for
an ongoing course of treatment or concurrent or continued hospitalization is terminated
or reduced, Molina Healthcare will provide you with notice and an opportunity to
appeal. For the ongoing course of treatment, coverage will continue during the appeal
process. The procedure will include a review by a health care provider who has not
previously reviewed the case and is of the same specialty or a similar specialty
as the health care provider who would typically manage the condition under appeal.
Upon receipt of an expedited Prior Authorization or concurrent clinical appeal,
Molina Healthcare will notify the party filing the appeal as soon as possible, but
in no event later than 24 hours after submission of the appeal, of all the information
needed to review the appeal. Molina Healthcare will render a decision on the appeal
within 24 hours after it receives the requested information, but no later than 72
hours after the appeal has been received by Molina Healthcare.
How to Appeal an Adverse Benefit Determination
An appeal of an Adverse Benefit Determination may be filed by You or a person authorized
to act on Your behalf, or Your health care provider. Your designation of a representative
must be in writing as it is necessary to protect against disclosure of information
about You except to Your authorized representative. To obtain an Authorized Representative
Form, You or Your representative may call Molina Healthcare at 1 (888) 560-2025.
Molina Healthcare will review its decision in accordance with the following procedure:
- Within 180 days after You receive notice of an Adverse Benefit Determination, You
may call or write to Molina Healthcare to request an appeal. We will need to know
the reasons why You do not agree with the Adverse Benefit Determination. Send Your
For review of claims for payment or reimbursement:
Molina Healthcare of Texas, Inc.
Attn: Grievance & Appeal Department
P.O. Box 165089
Irving, TX 75016
For appeal of requests for services, including Prior Authorization:
Molina Healthcare of Texas, Inc.
P.O Box 165089
Irving, TX 75016
Attn: Member Complaints & Appeals
We also will take telephone requests for an appeal. Within 5 working days from the
date we receive Your appeal, we will send You a letter acknowledging the date of
receipt, the procedures to be followed in the appeal and a list of documents that
You must submit for review. When we receive an oral appeal, we will send You a short
appeal form. In support of Your appeal, You have the option of presenting evidence
and testimony to us. You and Your authorized representative may ask to review Your
file and any relevant documents and may submit written issues, comments and additional
medical information within 180 days after you receive notice of an Adverse Benefit
Determination or at any time during the appeal process. A physician will make the
Molina Healthcare will provide You or Your authorized representative with any new
or additional evidence or rationale and any other information and documents used
in the review of Your appeal without regard to whether such information was considered
in the initial determination.
We will not rely on the initial Adverse Benefit Determination. Any new or additional
evidence or rationale will be provided to You or Your authorized representative
sufficiently in advance of the date a final decision on appeal is made in order
to give You a chance to respond. If the initial benefit determination regarding
the claim is based in whole or in part on a medical judgment, the appeal determination
will be made by a physician associated or contracted with Molina Healthcare and/or
by external advisors, but who were not involved in making the initial denial of
Your claim. Before You or Your authorized representative may bring any action to
recover benefits the claimant must exhaust the appeal process and must raise all
issues with respect to a claim and must file an appeal , and the appeal must be
finally decided by Molina Healthcare.
If you have any questions about the appeals procedures, write to us at the above
address or call us at 1(866)449-6849 ext. 752054. This appeal process does not prohibit
you from pursuing civil action available under the law.
Timing of Appeal Determinations
Molina Healthcare will make a determination of the appeal as soon as practical,
but in no event more than 30 days after the appeal has been received by us.
Notice of Appeal Determination
Molina Healthcare will notify the party filing the appeal, You, and, any health
care provider who recommended the services involved in the appeal, by a written
notice of the determination.
The written notice will include:
- The clinical basis for the determination;
- A reference to the benefit plan provisions on which the determination is based,
or the contractual, administrative or protocol basis for the determination;
- The specialty of the physician or other health care provider making the determination;
- In certain situations, a statement in non—English language(s) that written notice
of claim denials and certain other benefit information may be available (upon request)
in such non—English language(s) and how to access Molina Healthcare’s language services;
If the decision is a denial, the specialty of the physician or other health care
provider making the denial; and
- An explanation of Molina Healthcare's external review process to an Independent
Review Organization (and how to initiate an external review of the determination).
Your external review rights are described below in the Appeal to an Independent
Review Organization (IRO) section below.
APPEAL TO AN INDEPENDENT REVIEW ORGANIZATION (IRO)
You may request an appeal to an Independent Review Organization (“IRO”) of
a denial of an appeal of an Adverse Benefit Determination made by Molina Healthcare.
This procedure is not part of the complaint process and pertains only to appeals
of Adverse Benefit Determinations. In addition, in life-threatening or urgent care
circumstances, You are entitled to an immediate appeal to an IRO and are not required
to comply with Molina Healthcare's appeal of an Adverse Determination process.
Any party whose appeal of an Adverse Determination is denied by Molina Healthcare
may seek review of the decision by an IRO. At the time the appeal is denied, we
will provide You, Your designated representative or Provider of record, information
on how to appeal the denial, including any approved form, which You, Your designated
representative, or Your provider of record must complete. In life-threatening or
urgent care situations, You, Your designated representative, or Your provider of
record may contact Molina Healthcare by telephone to request the review and provide
the required information. For all other situations, You or Your designated representative
must request the IRO review in writing to Molina Healthcare to begin the independent
- Molina Healthcare will submit medical records, names of providers and any documentation
pertinent to the decision of the IRO within 3 business days of receiving Your request
for an IRO review.
- Molina Healthcare will comply with the decision by the IRO.
- Molina Healthcare will pay for the independent review.
Upon request and free of charge, You or Your designee may have reasonable access
to, and copies of, all documents, records and other information relevant to the
claim or appeal, including:
- information relied upon to make the decision;
- information submitted, considered or generated in the course of making the decision,
whether or not it was relied upon to make the decision;
- descriptions of the administrative process and safeguards used to make the decision;
- records of any independent reviews conducted by Molina Healthcare;
- medical judgments, including whether a particular service is Experimental or Investigational
or not Medically Necessary or appropriate; and
- expert advice and consultation obtained by Molina Healthcare in connection with
the denied claim, whether or not the advice was relied upon to make the decision.
The appeal process does not prohibit You from pursuing other appropriate remedies,
including: injunctive relief; a declaratory judgment or other relief available under
law, if the requirement to exhaust the process for appeal and review places your
health in serious jeopardy.
For more information about the IRO process, call Texas Department of Insurance (TDI)
on the IRO information line at (888) TDI-2IRO (834-2476), or in Austin call (512)