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
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.
- Member Services staff can help you file an appeal.
You can call Member Services at:
- (866) 449-6849
- TTY English (800) 735-2989 or dial 711
- Texas RelaySpanish (800) 662-4954
- Fax: (877) 816-6419
- Fill out the Appeal Form and mail or email to:
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.
State Fair Hearing
If you, as a member of the health plan, disagree with the health plan’s internal appeal decision, you have the right to ask for a State Fair Hearing. You may name someone to represent you by writing a letter to the health plan telling them the name of the person you want to represent you. A provider may be your representative. If you want to challenge a decision made by your health plan, you or your representative must ask for the State Fair Hearing within 120 days of the date on the health plan’s letter with the internal appeal decision. If you do not ask for the State Fair Hearing within 120 days, you may lose your right to a State Fair Hearing.
To ask for a State Fair Hearing, you or your representative should either send a letter to the health plan at
Molina Healthcare of Texas
Attention: Appeals and Grievances Department
P.O Box 165089
Irving, TX 75016
or call (866) 449-6849.
You have the right to keep getting any service the health plan denied or reduced, based on previously authorized services, at least until the final State Fair Hearing decision is made if you ask for a State Fair Hearing by the later of: (1) 10 calendar days following the date the health plan mailed the internal appeal decision letter, or (2) the day the health plan’s internal appeal decision letter says your service will be reduced or end. If you do not request a State Fair Hearing by this date, the service the health plan denied will be stopped. If you ask for a State Fair Hearing, you will get a packet of information letting you know the date, time and location of the hearing. Most State Fair Hearings are held by telephone. At that time, you or your representative can tell why you need the service the health plan denied.
HHSC will give you a final decision within 90 days from the date you asked for the hearing.
If you have questions about the process or status of your State Fair Hearing, you can call Member Services at (866) 449-6849, Monday-Friday, 8 a.m.-- 6 p.m., central time. You can learn more about State Fair Hearings in your member handbook.