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Members

You have the right to appeal a denial

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What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be given or bills will not be paid. If we deny your service or claim, you can ask why your services or bills were denied. You ask for an appeal. An appeal is a request that your health insurer or plan review a decision that denies a benefit or payment (either in whole or in part).

If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

Member Services staff can also help you file an appeal. You can call Member Services at:

·         (866)-449-6849

·         TTY English (800) 735-2989 or dial 711

·         Texas Relay Spanish (800) 662-4954

    ·        Fax: (877) 816-6419

Or

·         Fill out the Complaint/Appeal form​ and mail it to:

Molina Healthcare of Texas

Member Inquiry Research and Resolution Unit

P. O. Box 165089

Irving, TX 75016

   Be sure to include the following:

·         Member’s first and last name

·         Molina Healthcare ID number.  It is on the front of the Member ID Card

·         Member’s address and telephone number

·         Explain the problem

 

If you would like to check the status of your appeal, please call Member Services at (866) 449-6849.

If you are not happy with the result of your appeal for a disputed healthcare service, you can ask for a State Fair Hearing. This means that Texas Medicaid will provide for an external review outside Molina Healthcare to review all the facts in your case and make a decision. We will accept that finding.

Would you like to ask for a review of an appeal? Call Member Services and ask them to help set this up for you.

How to appeal a denial
If you receive a Notice of Action from Molina Healthcare, you have three (3) options for filing a complaint. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred or modified.

·         Medicaid members have 60 days to appeal from the date you receive the Notice of Action letter.

·         Medicaid members have 120 days to request a State Fair Hearing from the date you receive​ the Notice of Action letter.

*Note: Medicaid members can request both appeal and State Fair Hearing at the same time.


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