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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

Attention: Member Resolution Team

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 the Texas Health and Human Services Commission (HHSC) will provide for an external review outside Molina Healthcare to review all the facts in your case and make a decision. We will accept HHSC's 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 can file an appeal. 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 on the Notice of Action letter.

During the appeal process, you may be able to keep getting the services that were approved but are now being denied or limited. To keep getting these services, you must file your appeal and request continued services within 10 business days from the date on the letter telling you a service was denied or limited, or by the date that the services will end, whichever is later.

·         Medicaid members have 120 days to request a State Fair Hearing from the date on the Appeal Resolution letter. 

If you requested and continued receiving services during the appeal process, you can keep receiving these services during the State Fair Hearing process. To keep getting these services, you must request your State Fair Hearing within 10 business days from the date on the Appeal Resolution letter.

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


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