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Grievances

What is a grievance?

You have a right to file a grievance if you are unhappy with our plan or providers. A grievance is any complaint about Molina or a network provider that is not related to a decision Molina made about your health care services. You might file a grievance about things like the quality of services or care, rudeness from a provider or an employee, and not respecting your rights as a member.

Who can file a grievance?

You can file a grievance. An authorized representative, a legal decision maker, or a provider can also file a grievance for you. We will contact you for your permission if an authorized representative or provider files a grievance for you.

When can I file a grievance?

You (or your representative) can file a grievance at any time.

How do I file a grievance with Molina?

Call Molina Member Advocate at (888) 999-2404, or write to us at the following address if you have a grievance: Molina Healthcare of Wisconsin, Attn: Member Appeals and Grievances, P.O. Box 182273, Chattanooga, TN 37422.  If you file a grievance with Molina, you will have the opportunity to appear in-person or on the phone with the Molina Grievance and Appeal Committee. Molina will have 30 days from the date the grievance is received to give you a decision resolving the grievance.

Who can help me file a grievance?

Molina’s Member Advocate can work with you to solve the problem or help you file a grievance. If you want to talk to someone outside Molina about the problem, you can call the Wisconsin HMO Ombuds Program at (800) 760-0001. The Ombuds Program may be able to help you solve the problem or write a formal grievance to Molina. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at (800) 928-8778 for help with filing a grievance.

What if I disagree with Molina’s response?

If you don’t agree with Molina’s response to your grievance, you can request a review of your grievance with the Wisconsin Department of Health Services (DHS).

Write to:  BadgerCare Plus and Medicaid SSI HMO Ombuds, P.O. Box 6470, Madison, WI 53716-0470

Or call:    (800) 760-0001

Will I be treated differently if I file a grievance?

You will not be treated differently from other members because you file a complaint or grievance. Your health care and benefits will not be affected.

Appeals

What is an appeal?

You have a right to request an appeal if you are unhappy with a decision made by Molina. An appeal is a request for Molina to review a decision that affects your services. These decisions are called adverse benefit determinations.

An adverse benefit determination is any of the following:

•  Molina plans to stop, suspend, or reduce a service you are currently getting.

•  Molina decides to deny a service you asked for.

•  Molina decides not to pay for a service.

•  Molina asks you to pay an amount that you don’t believe you owe.

•  Molina decides to deny your request to get a service from a non-network provider when you live in a rural area with only one HMO.

•  Molina does not arrange or provide services in a timely manner.

•  Molina does not meet the required timeframes to resolve your grievance or appeal. Molina will send you a letter if you have received an adverse benefit determination.

Who can file an appeal?

You can request an appeal. An authorized representative (including an attorney), a legal decision maker, or a provider can also file an appeal for you. We will contact you for your permission if an authorized representative or provider requests an appeal for you, unless you give them written consent to do so using the consent form included with your denial letter.

When can I file an appeal?

You (or your representative) must request an appeal within 60 days of the date on the letter you get describing the adverse benefit determination.

How do I file an appeal with Molina?

If you would like to appeal an adverse benefit determination, you can call the Molina Member Advocate at (888) 999-2404 or write to the following address: Molina Healthcare of Wisconsin, Attn: Member Appeals and Grievances, P.O. Box 182273, Chattanooga, TN 37422. If you request an appeal with Molina, you will have the opportunity to appeal in-person or on the phone with the Molina Grievance and Appeal Committee. Once your appeal is requested, Molina will have 30 calendar days to give you a decision.

What if I can’t  wait 30 days for a decision?

If you or your doctor think that waiting 30 days could seriously harm your health or ability to perform your daily activities, you can request a fast appeal. If Molina agrees that you need a fast appeal, you will get a decision within 72 hours.

Who can help me request an appeal?

If you need help writing a request for an appeal, please call your Molina Member Advocate at (888) 999-2404. If you want to speak with someone outside Molina, you can call the BadgerCare Plus and Medicaid SSI Ombuds at (800) 760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at (800) 708-3034 for help with your appeal.

Can I continue to get the service during my appeal?

If Molina decides to stop, suspend, or reduce a service you are currently getting, you have the right to ask to keep getting your service during your appeal. You’ll have to mail, fax, or email your request within a certain timeframe, whichever is later:

•  On or before the date Molina plans to stop or reduce your service

•  Within 10 days of getting notice that your service will be reduced

If Molina’s decision about your appeal is not in your favor, you might have to pay Molina back for the service you got during the appeal process.

Will I be treated differently if I request an appeal?

You will not be treated differently from other members because you request an appeal. The quality of your health care and other benefits will not be affected.

What if I disagree with Molina’s decision about my appeal?

You can request a fair hearing with the Wisconsin Division of Hearing and Appeals if you disagree with Molina’s decision about your appeal. Learn more about fair hearings below.

Fair Hearings

What is a fair hearing?

A fair hearing is a review of Molina’s decision on your appeal by an Administrative Law Judge in the county where you live. You must appeal to Molina first before requesting a fair hearing.

When can I request a fair hearing?

You must request a fair hearing within 90 days of the date you get Molina’s written decision about your appeal.

How do I request a fair hearing?

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. 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, please call (608) 266-7709.

Who can help me request a fair hearing?

If you need help writing a request for a fair hearing, please call the BadgerCare Plus and Medicaid SSI Ombuds at (800) 760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at (800) 708-3034 for help.

Can I keep getting the service during myfair hearing?

If Molina decides to stop, suspend, or reduce a service you are currently getting, you have the right to ask to keep getting your service during your Molina appeal and fair hearing. You’ll have to request that the service continue during your fair hearing, even if you already requested to continue the service during your Molina appeal. You’ll have to mail, fax, or email your request within a certain timeframe, whichever is later:

•  On or before the date Molina plans to stop or reduce your service

•  Within 10 days of getting notice that your service will be reduced

If the administrative law judge’s decision is not in your favor, you might have to pay Molina back for the service you got during the appeal process.

Will I be treated differently if I request a fair hearing?

You will not be treated differently from other members because you request a fair hearing. The quality of your health care and other benefits will not be affected.

A fair hearing is a review of Molina’s decision on your appeal by an Administrative Law Judge in the county where you live. You must appeal to Molina first before requesting a fair hearing.

When can I request a fair hearing?

You must request a fair hearing within 90 days of the date you get Molina’s written decision about your appeal.

How do I request a fair hearing?

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. 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, please call (608) 266-7709.

Who can help me request a fair hearing?

If you need help writing a request for a fair hearing, please call the BadgerCare Plus and Medicaid SSI Ombuds at (800) 760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at (800) 708-3034 for help.

Can I keep getting the service during myfair hearing?

If Molina decides to stop, suspend, or reduce a service you are currently getting, you have the right to ask to keep getting your service during your Molina appeal and fair hearing. You’ll have to request that the service continue during your fair hearing, even if you already requested to continue the service during your Molina appeal. You’ll have to mail, fax, or email your request within a certain timeframe, whichever is later:

•  On or before the date Molina plans to stop or reduce your service

•  Within 10 days of getting notice that your service will be reduced

If the administrative law judge’s decision is not in your favor, you might have to pay Molina back for the service you got during the appeal process.

Will I be treated differently if I request a fair hearing?

You will not be treated differently from other members because you request a fair hearing. The quality of your health care and other benefits will not be affected