What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be rendered or bills will not be paid. If we deny your service or claim, you have the right to request why your services or bills were denied. You also have the right to appeal.
If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. This letter, called a Notice of Action, 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. If you are not happy with the result of your appeal for a disputed health care service, you can ask for an Independent Medical Review (IMR). This means providers outside Molina Healthcare 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 grievance. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred, or modified.
- Members have ninety (90) days from the date on the Notice of Action to file an appeal with Molina Healthcare. Members may file an appeal in person, in writing, by e-mail, fax, TTY or telephone. We will send the member a letter acknowledging receipt of the appeal within five (5) calendar days. All levels of Molina Healthcare’s grievances and appeal procedures will be completed in thirty (30) calendar days.
- Members may request a State Fair Hearing from the Department of Social Services (DSS) within ninety (90) days.
- Members may request an Independent Medical Review (IMR) from the Department of Managed Health Care (DMHC).
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