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:
· Fax: (877) 816-6419
TTY English (800) 735-2989 or dial 711
Texas Relay Spanish (800) 662-4954
Fill out the Complaint/Appeal form and mail it
Molina Healthcare of Texas
Attention: Member Resolution Team
P. O. Box 165089
Irving, TX 75016
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)
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.