Adverse benefit determination
Adverse benefit determinations include actions, such as the denial, reduction, or limitation of services or payments, that providers should understand when delivering and managing member care.
Standard appeals
If you, as a provider, disagree with a decision regarding Molina health benefits for a member, you can submit an appeal for review. 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 requests a faster review of 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 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 Molina’s provider dispute policies.