How to Appeal a Denial
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What is a denial?
A denial means Molina Healthcare is telling a provider and you that services will not be provided (or they will be reduced or ended early), 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. If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. You have the right to appeal a denial. This denial letter will tell you how to file an appeal. You can also read about these rights in your Member Handbook.
What is an appeal?
An appeal is a request to review a denied referral, or a service that was denied, reduced, or ended early.
How do I appeal a denial?
If you receive a denial letter from Molina Healthcare, you or your authorized representative have the right to file an appeal. An authorized representative is someone you choose to act on your behalf. They can be an attorney or a provider, or another person you trust. You must sign a consent form allowing this person to represent you. Molina Healthcare does not cover any fees or payments to your representatives. That is your responsibility.
You have 60 calendar days after the date of Molina Healthcare’s denial letter to ask for an appeal.
You or your representative may request an appeal over the phone, in person, or in writing. If you request an appeal by phone, you must also send it in writing to us with your signature. You have the right and the opportunity to submit written comments, documents or other additional information relevant to the appeal. Additional information (including comments and/or documents) to support your appeal may be submitted over the phone, in writing, or in person.
There are four steps in the appeal process:
STEP 1: Molina Healthcare Standard and Expedited Appeal
STEP 2: State Administrative Hearing
STEP 3: Independent Review
STEP 4: Health Care Authority (HCA) Board of Appeals Review Judge Decision
How do I ask for (file) an appeal?
- Call* Molina Healthcare’s Member Services department at (800) 869-7165, TTY 711;
- Write your appeal request and fax it to (877) 814-0342;
- Or write your appeal request and mail it to:
Attn: Member Appeals
PO Box 4004
Bothell, WA 98041-4004
*If you request an appeal by phone, you must also send it in writing to us with your signature.
If you need help filing an appeal, call Member Services at (800) 869-7165, TTY 711. You also have the right to receive assistance from the Ombuds with filing the appeal. If you need information about how to contact your local Ombuds, call (800) 869-7165, TTY 711, or go to MolinaHealthcare.com/waombuds.
When will I find out that my appeal has been received?
Within five calendar days, , we will let you know in writing that we got your standard appeal. If you file an expedited (faster) review, we will let you know within 72 hours. We will tell you and/or your authorized representative if there is a delay and will resolve your appeal as quickly as your health requires.
Can I get access to the information in my appeal file?
Yes. Before or during the appeal, you or your representative may request copies of all the documents in your appeal file, and the guidelines or benefit provisions used to make the decision. These will be sent to you free of charge. We will keep your appeal private.
When will my appeal be resolved?
We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days. We will keep your appeal private.
Continuation of Services During the Appeal Process
If you want to keep getting previously approved services while we review your appeal, you must file your appeal within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our decision, you may need to pay for services you received during the appeal process.
Expedited (Faster) Appeals
If you or your provider want a quick decision because your health is at risk, call (800) 869-7165, TTY 711, for an expedited (faster) review of the denial. You may ask for an expedited review if your physical or mental health is at serious risk, or it involves a mental health drug authorization. You may file an expedited appeal either orally or in writing. If you file the expedited appeal orally, written follow up is not required. We will review your request and contact you with our decision within 72 hours of getting your request.
The expedited timeframe may be extended up to 14 calendar days if we need more information to process your appeal, and if the delay is in your best interest. If Molina Healthcare extends the timeframe, we will send you a letter within two calendar days of your appeal request. We will tell you why the extension is needed. You can also ask for an extension.
If you ask for an expedited appeal but Molina Healthcare decides your health is not at risk, we will follow the regular appeal process time to make our decision. We will send you a letter telling you the decision and the reason for the change within two calendar days of your appeal request.
Appeals for Wraparound Services
You have 60 calendar days after the date of Molina Healthcare’s denial letter to ask for an appeal for wraparound services. You or your representative may submit information about your case in person or in writing. If you want copies of the guidelines we used to make our decision, we can give them to you free of charge. We will keep your appeal private. We will send you our decision in writing within 14 calendar days, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent.
When State-Only (GFS) funding for a requested service is exhausted, any appeals process, independent review, administrative hearings process will be terminated since services cannot be authorized without funding regardless of medical necessity.