What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be given or bills will not be paid. If we deny your service or claim, you can ask why your services or bills were denied. You ask for an appeal.
If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.
Member Services staff can also help you file an appeal. You can call Member Services at:
· (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-6826
· TTY English (800) 735-2989 or dial 711
· Texas Relay Spanish (800) 662-4954
Fill out the Complaint / Appeal form and mail
Molina Healthcare of Texas
Member Inquiry Research and Resolution Unit
P.O. Box 165089
Irving, TX 75016
· Be sure to include the following:
· Member's first and last name
· Molina Healthcare ID number. It is on the front of the Member ID Card
· Member's address and telephone number
· Explain the problem
If you would like to check the status of your appeal, please call Member Services at (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-3826.
If you are not happy with the result of your appeal for a disputed healthcare service, you can ask for an independent medical review from an Independent Review Organization (IRO). This means providers outside Molina Healthcare review all the facts in your case and make a decision. We will accept that finding.
Would you like to ask for a review of an appeal? Call Member Services and ask them to help set this up for you.
appeal a denial
If you receive a Notice of Action from Molina Healthcare, which is a formal letter telling you that a medical service has been denied, deferred or modified, the following applies:
· CHIP members have 180 days to request an appeal from the date the Notice of Action letter is mailed.
· CHIP members may request an IRO (Independent Review Organization)
· *Note: CHIP member must request an appeal and go through the entire appeal process before requesting an IRO. If Appeal is NOT in member's favor, the member can request an IRO.
· CHIP members may appeal directly to an IRO when their condition is life threatening and bypass the internal Molina appeal process.