When should I go to the emergency room? Sometimes it can be hard to know if a health problem is a medical emergency. This guide will help you determine if you need to go to the emergency room or if you can wait for an appointment with your primary care provider (PCP).
What is an emergency?
An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if it is not treated immediately. If you are having an emergency, don’t wait! Call 911 or go to the emergency room right away.
Call 911 or go to the ER for:
Coughing or vomiting blood
Sudden weakness or drooping on one side of body
Severe allergic reaction
Suicidal or homicidal feelings
Confusion of change in mental state
High fever (105 degrees F)
Swallowing of obstructive object (coins, magnets, small toy parts)
Major head injury
If you aren’t sure you have an emergency, you can call the Molina Healthcare Nurse Advice Line.
If you aren’t sure if you should wait to see your PCP, call the Nurse Advice Line and ask. You can reach a nurse 24 hours a day, 7 days a week to answer your health questions.
If you do go to the ER, remember to:
Contact your PCP and let him or her know you are planning to go or have gone to the ER
Bring a list of your providers’ names
Bring your Molina member ID card
Bring all your medications with you
When to see your PCP If you are having an issue that isn’t life-threatening, you can call your PCP’s office and make an appointment. Your PCP is familiar with you and your medical history. He or she can help you with health concerns that aren’t putting you in immediate danger.
Examples of non-emergencies:
Colds, cough, flu, mild fever
Sprain or strain
Minor cuts, bruises or burns
Nausea, vomiting or diarrhea
Joint and back pain
Tooth or dental pain
Minor asthma attack
Mild allergic reaction
Urinary tract infection
Running out of your medicine
Medication side effects
If your PCP is closed or not available, please consider going to a local in-network urgent care clinic for issues that are non-emergencies. Your Care Manager can assist you with finding an urgent care clinic in your area.
Behavioral Health Crisis If you are experiencing a behavioral health crisis, call our behavioral health crisis line and we will find a crisis provider for you. If your symptoms include thoughts about harming yourself or someone else, call 911 or get to the closest emergency room right away.
Behavioral Health Crisis Line (available 24/7/365) Cardinal Care Managed Care: (800) 424-4518 (TTY 711)
There are some treatments, services and drugs that require approval from us before you can get them. This is called a service authorization. You or your doctor can ask for a service authorization. Call Member Services to ask if a service or treatment needs a service authorization.
After you or your doctor asks us for a service authorization, we review the request to decide if the treatment is medically needed and right for you. We will let you know if the request is approved within 14 calendar days. If waiting more than 14 days could seriously harm your health, your doctor can ask us to do an expedited review. If your doctor asks for an expedited review, we will let you know if the request is approved within 3 calendar days, or as quickly as your health condition requires.
If you disagree with our decision, you can file an appeal. You can read more about how to do that on this page. Look in your Member Handbookfor more information about service authorizations.
An appeal is a way for you to challenge an adverse benefit determination (a denial or reduction in benefits) made by Molina Healthcare of Virginia if you think we made a mistake. You can ask us to change our decision by filing an appeal.
What is a grievance?
A grievance is a complaint you make about us or one of the providers or pharmacies in the Molina network. This includes a complaint about the quality of your care.
How do I file an appeal?
If you are not satisfied with a decision we made, you have 60 calendar days to file an appeal. You can file the appeal yourself or ask someone to file the appeal for you. You can call Member Services if you need help filing an appeal.
You can file an appeal by phone or in writing. You can send your appeal as a standard appeal or an expedited (fast) request.
Check your Member Handbook for complete instructions on how to file an appeal.
How do I file a grievance?
You can file a grievance (complaint) at any time. There are different types of grievances. An internal grievance is a complaint you want to file with Molina. To file an internal grievance, you can call Member Services or send the complaint to us in writing.
An external grievance is a complaint you make to the state or a state agency about Molina or one of our network providers or pharmacies.
Check your Member Handbook for complete instructions on how to file a grievance.
Fraud refers to a false action that is used to gain something of value
Waste is the misuse of services
Abuse refers to overused or unneeded services
Molina is dedicated to conducting business in a legal manner. We are committed to preventing, detecting and reporting fraud, waste and abuse. In addition, the Division of Medicaid Program Integrity wants to prevent fraud, waste and abuse. They check on anybody including members, providers, and vendors who may be trying to commit fraud, waste or abuse against the Medicaid program. They also:
Send possible fraud cases for investigation
Examples of fraud, waste and abuse:
Medical identity theft
Billing for unnecessary items or services
Billing for items or services not provided
Billing a code for a more expensive service or procedure than was performed (known as up-coding)
Charging for services separately that are generally grouped into one rate (Unbundling)
Items or services not covered
When one doctor receives a form of payment in return for referring a patient to another doctor. These payments are called “kickbacks”
How can I report fraud, waste or abuse? You may report fraud, waste or abuse by contacting us in any of the ways listed below:
Virginia Medicaid Fraud Control Unit (Office of the Attorney General)
Fax: (804) 786-3509
Office of the Attorney General
Medicaid Fraud Control Unit
202 North Ninth Street
Richmond, VA 23219
Molina helps prevent fraud, waste and abuse by verifying services. We may send you a form asking if you received the services we paid your doctor for. Please fill it out and mail it back in the pre-addressed, postage-paid envelope we send with the form. If you tell us that you did not get the services, we will also report it to DMAS.
You can change your primary care provider (PCP) with Molina at any time. Call Member Services at (800) 424-4518 (TTY 711) to change your PCP to another PCP in our network. It is possible that your PCP might leave our network. If this happens, we will tell you within 30 days from when we know about this. We can help you find a new PCP right away.
Viewing your claims with Molina is easy. Just login to the Member Portal at the top of this page. Then, select “Claims & Authorizations” from the menu at the top of the page. You’ll see your current claims listed under the “Claims” heading on the page. You can use the “Filter Claims” option to narrow down what you are looking for.
It is important for you to take your Health Risk Assessment (HRA). Your answers will help us understand your needs and allow us to provide you with the best level of care.
For Cardinal Care Managed Care members who have a care manager, they will call you to conduct your HRA over the phone. If you are a Cardinal Care Managed Care member and you do not have a care manager, you do not need to complete an HRA.
An individualized care plan includes the types of health services that you need and how you will get them, as well as your personal goals for your health. It’s based on your Health Risk Assessment (HRA) and individual needs and goals. After you complete your HRA, your care team will talk to you about what kind of healthcare you need. They will also ask you about your goals and preferences.
Together, you and your care team will make a personalized care plan, specific to your needs. Your care team will work with you to update your care plan when your healthcare needs change, and at least once per year.