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. 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.
Member Appeals
Members can appeal our decision if a service was denied, reduced, or ended early. Here are the steps in the appeal process:
STEP 1: Molina Healthcare Appeal
STEP 2: Administrative Hearing
STEP 3: Independent Review
STEP 4: Health Care Authority (HCA) Board of Appeals Review Judge
Continuation of Services During the Appeal Process
If a Member wants to keep receiving previously approved services while we review the appeal, the appeal must be filed within ten (10) calendar days of the date on the denial letter. If the final decision in the appeal process agrees with our decision, the Member may need to pay for services they received during the appeal process.
STEP 1 – Molina Healthcare Appeal
Members have 60 calendar days after the date of Molina’s denial letter to ask for an appeal. The Member or their representative may request an appeal over the phone, in person, or in writing. Additional information to support the appeal may also be submitted over the phone, in writing, or in person. Within five (5) calendar days, we will let the Member know in writing that we received the appeal.
Members can file an appeal in the following ways:
Mail:
Molina Healthcare
Attention: Member Appeals
PO Box 4004
Bothell, WA 98041-4004
Web: MolinaHealthcare.com
Phone: (800) 869-7165 (TTY 711)
Fax: (877) 814-0342
Email: WAMemberServices@MolinaHealthcare.com
A Member may choose someone, including a lawyer or Provider, to represent them and act on their behalf. However, they must sign a consent form allowing this person to represent them. It is the Member’s responsibility to cover any fees or payments to representatives.
Before or during the appeal, the Member or their representative may request copies of all the documents in the appeal file and the guidelines or benefit provisions used to make the decision, free of charge. Molina will send our decision in writing within 14 calendar days unless we notify them we need more time. Our review will not take longer than 28 calendar days.
If the Member needs an expedited decision because the Member’s health is at risk, call (800) 869-7165 (TTY 711) for a quick review (called “expedited” review) of the denial.
Members can file an expedited appeal either orally or in writing. Molina will contact the
Member with our decision within 72 hours of receiving the request for an expedited review.
If an expedited appeal is requested but Molina decides the Member’s health is not at risk, we will follow the regular appeal timeframe. We will send a letter with the decision and a reason for the change within two (2) calendar days of the appeal request.
The expedited timeframe may be extended up to 14 calendar days if additional information to process the appeal is needed and the delay is in your best interest. If Molina extends the timeframe, we will send a letter within two (2) calendar days of the appeal request and a reason for the extension.
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.