How to Appeal a Denial
You have the right to appeal a denial
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 denial letter will tell you about your right to appeal. You can also read about these rights in your Member Handbook.
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How to appeal a denial
If you receive a denial letter from Molina Healthcare, there are four steps in the appeal process:
STEP 1: Molina Healthcare Appeal
STEP 2: State Hearing
STEP 3: Independent Review
STEP 4: Review Judge Decision
If you need help filing an appeal, call Member Services at (800) 869-7165. Within 72 hours, we will let you know in writing that we got your appeal. You may choose someone, including an attorney or provider, to represent you and act on your behalf. 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 90 calendar days after the date of Molina Healthcare’s denial letter to ask for an appeal. 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 after receipt of the appeal, unless we tell you we need more time. Our review will not take longer than 28 calendar days, unless you give us written consent. If you give us written consent our review will not take longer than 45 days.
Continuation of Services During the Appeal Process
If you want to keep getting previously approved services while we review your appeal, you must tell us within 10 calendar days of the date on your denial letter. If the final decision in the appeal process agrees with our action, you may need to pay for services you received during the appeal process.
Expedited (Faster) Decisions
If you or your provider think waiting for a decision would put your health at risk, ask for an expedited (faster) appeal, state hearing, Independent Medical Review or HCA Review Judge Decision. We will review your request and make a decision within three (3) calendar days. If we decide your health is not at risk, we will follow the regular appeal process time to make our decision.
Appeals for Wraparound Services
You have 90 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 3 calendar days, unless we tell you we need more time. Our review will not take longer than 14 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.