Filing a Grievance or Appeal
A grievance is any complaint (concern) about Molina or a health care provider. Grievance topics include things like the quality of services you were provided, rudeness from a provider or an employee, and not respecting your rights as a member. Molina would like to know if you have a grievance about your care.
You may also send a grievance if you are not able to find an in-network doctor who gives you cultural and language services and care you need.
You have the right to appeal if you believe your benefits are wrongly denied, limited, reduced, delayed, or stopped by Molina Healthcare of Wisconsin.
When requesting an appeal, you must appeal to Molina first. The request for an appeal must be made no more than 60 days after you receive notice of services being denied, limited, reduced, delayed, or stopped. Once Molina has received your appeal, Molina has 30 days to research and resolve. Once a resolution is reached you will receive that resolution in writing.
You may request to have the disputed services continued while the Molina appeal and State fair hearing process are occurring. The request to continue services must happen within 10 days of receiving the notice that services were denied or changed, or before the effective date of the denial or change in benefits. You may need to pay for the cost of services if the hearing decision is not in your favor.
Asking for a Fast Appeal
You can ask for a faster decision on your appeal if you or your doctor think that waiting 30 days could seriously harm your health or ability to perform your daily activities. This is called an “expedited” or fast appeal. Your doctor must send written documentation about why a fast appeal is needed. If Molina agrees that you need a fast appeal, you will get a decision within 72 hours. If Molina decides you do not need a fast appeal, you will get a letter letting you know why the request for a fast appeal was denied, and your appeal will be decided within 30 days.
How to Send a Grievance or Appeal
You can send Molina a grievance or appeal in the following ways:
- Call: Molina Member Services at 1-800-999-2404, TTY: 711 to speak with a Molina representative. You can also ask for your Member Advocate. Note: if you call with an appeal, you will need to follow up in writing
Molina Healthcare of Wisconsin
PO Box 242480
Milwaukee, WI 53224-9931
- Fax: 844-251-1445
- Email: WIMemberAppeals@MolinaHealthCare.Com
You can give permission for your doctor or another person to submit a grievance or appeal on your behalf. You must give them consent to do so in writing.
You may use the Grievance Consent Form to submit your grievance or appeal but it not required. The Grievance Consent Form canbe used to give consent for another person to file a grievance or appeal on your behalf.
If you need help outside Molina
If you want to talk to someone outside Molina about the problem, you can contact:
- For help with a grievance or appeal: HMO Enrollment Specialist at 1-800-291-2002. The HMO Enrollment Specialist may be able to help you solve the problem or write a grievance or appeal to Molina or to the BadgerCare Plus and/or Medicaid SSI programs.
- For help with an appeal: BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001
- If you are enrolled in a Medicaid SSI Program: SSI External Advocate at 1-800-928-8778 for help with grievances or appeals
Your Next Level Appeal Rights (State Fair Hearing)
If you disagree with Molina’s decision about your appeal, you may request a State Fair Hearing with the Wisconsin Division of Hearing and Appeals. The request for a State Fair Hearing must be made no more than 90 days after Molina makes a decision about your appeal.
If you want a State Fair Hearing, send a written request to:
Department of Administration
Division of Hearings and Appeals
PO Box 7875
Madison, WI 53707-7875
The hearing will be held with an administrative law judge in the county where you live. You have the right to be represented at the hearing, and you can bring a friend for support. If you need a special arrangement for a disability or for language translation, call 1-608-266-3096 (voice) or 1-608-264-9853 (hearing impaired).
If you need help writing a request for a State Fair Hearing, call Molina Member Services at 1-800-999-2404, TTY: 711 to speak with a Molina representative. You can also ask for your Member Advocate. You can also call the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001 or the HMO Enrollment Specialist at 1-800-291-2002. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at 1-800-928-8778 for help.
You will not be treated differently from other members because you request a State Fair Hearing. Your health care benefits will not be affected.