Member Complaints, Grievances and Appeals
You may not always be happy with Molina. We want to hear from you. Molina has people who can help you. Molina cannot take your benefits away or charge you any fees because you make a grievance, appeal, or ask for a State Fair Hearing. We would like to know if you have a complaint about your care at Molina Healthcare Health Plan. There are two (2) ways to tell Molina about a problem:
Grievance or Appeal
A Grievance is a way for you to show dissatisfaction about things like:
- The quality of care or services you received
- The way you were treated by a provider or
- A disagreement you may have with a Health plan policy
An Appeal is a way for you to ask for a review when your health plan:
- Denies or give a limited approval of a requested service
- Denies, reduces, suspends or ends a service already approved or
- Denies payment for a service or fails to
- Act within required time frames for getting a service
- Respond to a grievance or appeal issue within the required response times identified below
Molina must provide written Notice of Action if any of these actions happen. The Notice of Action will tell you what we did and why and give you your rights to appeal or ask for a State Fair Hearing.
Molina Healthcare will send you something in writing if we make a decision to:
- Deny a request to cover a service for you
- Reduce, suspend or stop services before you receive all of the services that were approved or
- Deny payment for a service you received that is not covered by Molina Healthcare.
We will also send you something in writing if, by the date we should have, we did not:
- Make a decision on whether to okay a request to cover a service for you or
- Give you an answer to something you told us you were unhappy about.
Molina must write you within 10 days and let you know we received your appeal.Molina must provide written notice of a decision within 30 days unless it is an expedited review. The maximum time Molina can take to resolve a grievance or appeal is 45 days.
You have some Special Rights when Making a Grievance or Appeal:
- A qualified clinical professional will look at medical grievances or appeals.
- If you do not speak or understand English, call 1-888-999-2404 to get help from someone who speaks your language.
- You may ask anyone such as a member advocate, family member, your minister, a friend, or an attorney to help you make a grievance or an appeal.
If your physical or behavioral health is in danger, a review will be done within 3 working days or sooner. This is called an expedited review. Call Molina and tell Molina if you think you need an expedited review.
Please call Molina Healthcare Health Plan's Member Advocates at 1-888-999-2404 or 1-800-947-3529 if you have a complaint or you can write us at:
Molina Healthcare of Wisconsin
Attn: Grievance/Complaint Department
PO Box 242480,
Milwaukee, WI 53224-9931.
If you want to talk to someone outside of the Molina Healthcare Health Plan about the problem, call the HMO enrollment specialist at 1-800-291-2002. The enrollment specialist may be able to help you solve the problem, or can help you write a formal grievance to Molina Healthcare Health Plan or to the BadgerCare Plus and Medicaid SSI Programs.
You may also file a complaint with the Wisconsin BadgerCare Plus and Medicaid SSI Program. Please call Molina Healthcare's Member Advocate if you need help to write a formal grievance to Molina Healthcare Health Plan or to the BadgerCare Plus and Medicaid SSI Programs.
The address to complain to the Wisconsin BadgerCare Plus and Medicaid SSI Programs is:
BadgerCare Plus and Medicaid SSI
Managed Care Ombuds
P.O. Box 6470
Madison, WI 53716-0470
If your complaint or grievance needs action right away because a delay in treatment would greatly increase the risk to your health, please call Molina Healthcare as soon as possible at 1-888-999-2404 or 1-800-947-3529.
We cannot treat you differently than other members because you file a complaint. Your healthcare benefits will not be affected.
You have the right to appeal to the State of Wisconsin Division of Hearings and Appeals (DHA) for a Fair Hearing. If you believe your benefits are wrongly denied, limited, reduced, delayed or stopped by Molina Healthcare Health Plan, an appeal must be made no later than 45 days after the date of the action being appealed. If you appeal this action to DHA before the effective date, the service may continue. You may need to pay for the cost of services if the hearing decision is not in your favor.
Molina Healthcare will notify you of your right to request a state hearing when:
- A decision is made to deny services.
- A decision is made to reduce, suspend, or stop services before all of the approved services are received.
- A provider is billing you because Molina Healthcare has denied payment of the service.
If you want a Fair Hearing, send a written request to:
Department of Administration
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707-7875
The hearing will be held in the county where you live. You have the right to bring a friend or be represented at the hearing. If you need a special arrangement for a disability, or for English language translation, please call 608-266-3096 (voice) or 608-264-9853 (hearing impaired).
We cannot treat you differently than other members because you request a Fair Hearing. Your health care benefits will not be affected.
If you need help writing a request for a Fair Hearing, please call either the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001 or HMO Enrollment Specialist at 1-800-291-2002.
We want you to have access to the complaint and grievance process and can help you through each step.