Members

How to File an Appeal

appeal

Appeals

If you are unhappy with anything about Molina Healthcare or its providers, you should contact us as soon as possible. This includes if you do not agree with a decision we have made. You, or someone you want to speak for you, can contact us.

If you want someone to speak for you, you will need to let us know this. Molina Healthcare can help you with this process by calling Member Services. These services are free of charge. You can call us at (844) 809-8438, TTY/TDD 711 Monday to Friday from 7:30 a.m. to 8 p.m. (CST) and the second Saturday and Sunday of every month from 8 a.m. to 5 p.m. (CST).

A translator is available if you need to speak in your own language and can help you file your complaint, grievance, or appeal request. This service is free to all of our members.

If you got a Notice of Adverse Benefit Determination (denial letter) and you are unhappy with Molina’s decision, you can ask for an Appeal.

An Appeal is a request to look at an adverse benefit determination made by Molina. An adverse benefit determination (a decision not made in your favor) can be:

  • Limiting or denying services;
  • Reducing services;
  • Suspending services;
  • Terminating services;
  • Denying payment for services;
  • Failing to provide services in a timely manner;
  • Failing to resolve appeals and grievances within timeliness guidelines;
  • For a resident of a rural area with only one (1) Managed Care Organization in the area, the denial of a request to exercise his or her right to get services outside the Molina network;
  • The denial of a request to dispute a financial responsibility, including cost sharing, co-payments, premiums, deductibles, coinsurance, and other member financial responsibilities; or
  • If applicable, decisions by skilled nursing facilities and nursing facilities to transfer or discharge residents and adverse determinations made by a State about the preadmission screening and annual resident review requirements.

 

Filing an Appeal

All appeals must be filed within sixty (60) calendar days from the date on the Notice of Adverse Benefit Determination (denial letter).We will send you a letter letting you know that we got your appeal within ten (10) calendar days of getting the appeal.

To file your appeal you can:

 

We can accept your appeal from someone else with your permission. For Example:

  • A friend
  • A family member
  • A provider part of Molina
  • A provider that is not part of Molina
  • A lawyer

If you need a copy of the Appeal Request Form you can call Member Services or download and print a copy. If you send us your grievance/appeal request in writing, please include the following information:

  • Your first and last name
  • Your signature
  • Date
  • Your Member ID number which can be found on the front of your Molina member ID card
  • Your address and telephone number
  • Your PCP’s name and telephone number
  • A description of the issue
  • Any records related to your request

 

Mail the letter or fax the form to:

Molina Healthcare

Attention: Member Grievances and Appeals

1020 Highland Colony Parkway, Suite 602

Ridgeland, MS 39157

Phone: (844) 809-8438, TTY/TDD: 711

Fax: (844) 808-2407

We may call your provider or get help from other Molina departments to investigate your appeal. You will get a letter with the outcome of your appeal as quickly as your health condition requires, but no later than thirty (30) calendar days from when we got the appeal request.

  • You can ask for up to fourteen (14) extra calendar days to resolve your appeal, or
  • Molina can take up to fourteen (14) extra calendar days if we need more information for your appeal.
  • We will call you and send you a letter within two (2) calendar days of extending the timeframe.
  • The letter will include the reason why we need more time and how the delay is in your best interest.

 

You have the opportunity to present Molina with evidence of the facts or law about your case, in person or in writing.

Your appeal will be looked at by an individual with the appropriate clinical knowledge for your condition. In order to be fair, your appeal will be looked at by someone who was not involved in any previous level of review and is not an employee of the individual who made the first decision.

You, or someone legally authorized to do so, can ask us for a complete copy of your case file at any time, including medical records (subject to Health Insurance Portability and Accountability Act (HIPAA) requirements), a copy of the guidelines (criteria), benefits, other documents and records, and any other information related to your appeal. These can be provided free of charge.

 

Expedited Appeals

You, your provider, or your Authorized Representative can ask for an expedited (fast) appeal if you think that waiting thirty (30) calendar days for an appeal decision could put your life, health, or your ability to attain, maintain, or regain maximum function in danger. Molina can also expedite (rush) your appeal request based on the information we get.

Molina will decide if your request meets the guidelines for an expedited appeal resolution within twenty-four (24) hours of getting your expedited appeal request. If your appeal request does not meet the guidelines for an expedited (fast) appeal, we will still process your plan appeal within the regular thirty (30) calendar day timeframe.

We will call you and send you a letter with this information within two (2) calendar days of getting your expedited appeal request. If we do expedite (rush) your plan appeal, we will call you and send you a letter with the appeal resolution within seventy-two (72) hours of getting your expedited appeal request.

Expedited (fast) appeals will be resolved as quickly as your health condition requires, but no more than seventy-two (72) hours from when we get the expedited appeal request. Please note the limited time available to present evidence if we expedite your appeal.

  • You can ask for up to fourteen (14) extra calendar days to resolve your expedited appeal. Or,
  • Molina can take up to fourteen (14) extra calendar days if we need more information for your expedited appeal.
  • We will call you and send you a letter within two (2) calendar days of extending the timeframe.
  • The letter will include the reason why we need more time and how the delay is in your best interest.

 

At any time you may request for a copy of your file, medical records or any material free of charge.

 

Continuing Your Benefits During the Appeal Process

If you would like to continue with your benefits while you are appealing, you must file an appeal and meet all of the following guidelines:

  • You asked for your benefits to continue within ten (10) calendar days from the date on the denial letter, or Notice of Adverse Benefit Determination letter, or on or before the date when changes to your benefit start, which date is later;
  • The appeal involves services that Molina had already authorized;
  • The service must have been asked for by an approved provider
  • The approved authorization has not expired; and
  • You asked for an extension of benefits.

 

Molina will provide benefits until one (1) of the following occurs:

  • You withdraw the appeal;
  • Ten (10) calendar days have passed from the date of the notice of appeal resolution and you have not asked for a Medicaid State Fair Hearing;
  • The Division of Medicaid makes a State Fair Hearing decision not in your favor; or
  • The time period or service limits of a previously authorized services has expired.

 

To ask for your benefits to continue while your appeal is being looked at, you may call us or send your request in writing to:

Molina Healthcare of Mississippi

Attention: Grievance & Appeals Department

1020 Highland Colony Parkway, Suite 602

Ridgeland, MS 39157

Fax: (844) 808-2407

If the final Appeal decision is not in your favor, you may have to pay for the services you were getting while the appeal was being reviewed. If the final appeal decision is in your favor and the services were not given to you while the appeal was being looked at, Molina will authorize the services for you as quickly as your health requires, but no later than seventy-two (72) hours from the date of the approval.