Appeals, Grievances, and State Fair Hearings Definitions
Adverse Benefit Determination
An Adverse Benefit Determination is when we:
- Deny payment for care or approve payment for less care than you wanted.
- Lower the number of services you can get or end payment for a service that was approved.
- Deny payment for a covered service.
- Deny payment for a service that you may be responsible to pay.
- Did not decide on an appeal or grievance in a timely manner.
- Did not provide you with a doctor’s appointment in a timely manner. Timely manner means 30 days for a routine doctor visit and two days for an urgent care visit.
- Deny a member’s request to dispute a financial liability.
You have a right to receive a Notice of Adverse Benefit Determination if one of the above occurs. If you did not receive one, contact Member Services and we will send you a notice.
An appeal is when you, your authorized representative, or your provider contacts us to review an Adverse Benefit Determination to see if the right decision was made to deny your request for service.
A grievance is a complaint about the way your health care services were handled by your provider or Molina.
State Fair Hearing
A State Fair Hearing is a hearing you, your authorized representative, or your provider can request with the State Medicaid/CHIP Hearings Unit if you are unhappy with our decision about your appeal.