Adverse Benefit Determination
Adverse benefit determinations encompass various actions, such as denial, reduction or limitation of services or payments, that providers need to be aware of when delivering and managing member care.
Standard Appeals
If you, as a provider, disagree with a decision regarding Molina health benefits for your member, you can submit an appeal for review on behalf of the member During the appeal process, Molina will notify you of your rights, qualified professionals will review your case and Molina will communicate the outcome, including further options if they uphold the denial.
Expedited Appeals
An expedited appeal asks Molina to quickly review an adverse benefit decision involving hospital admission, continued stay or other health services if waiting for a standard appeal could seriously risk the member's life, health or recovery.
State Fair Hearings
The State Fair Hearing system offers providers with a structured process for assisting members with appeals beyond Molina’s internal review.
Provider Claim Disputes
Providers can request a review of previously processed claims, following Molina’s established redetermination procedures. This process ensures Molina handles claims disputes and adjustments promptly and transparently.
For more information, see our Provider Dispute Policies.