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When should I go to the emergency room?
Sometimes it can be hard to know if a health problem is a medical emergency. This guide will help you determine if you need to go to the emergency room or if you can wait for an appointment with your primary care provider (PCP).

What is an emergency?
An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if it is not treated immediately. If you are having an emergency, don’t wait! Call 911 or go to the emergency room right away.

Call 911 or go to the ER for:

• Trouble breathing
• Chest pains
• Heavy bleeding
• Coughing or vomiting blood
• Serious burn
• Sudden weakness or drooping on one side of body
• Severe allergic reaction
• Suicidal or homicidal feelings
• Confusion of change in mental state
• Broken bone
• High fever (105 degrees F)
• Fainting
• Swallowing of obstructive object (coins, magnets, small toy parts)
• Major head injury
• Palpitations
• Uncontrollable shaking
• Seizures

If you aren’t sure you are having an emergency, you can call the Molina Healthcare (Molina) Nurse Advice Line.

  (833)-965-1558 (TTY: 711)

If you aren’t sure if you should wait to see your PCP, call the Nurse Advice Line and ask. You can reach a nurse or behavioral health professional 24 hours a day, 7 days a week to answer your health questions.

If immediate assistance is needed call 911.

If you do go to the ER, remember to:

• Contact your PCP and let him or her know you are planning to go or have gone to the ER
• Bring a list of your providers’ names
• Bring your Molina member ID card
• Bring all your medications with you

When to see your PCP
If you are having an issue that is not life-threatening, you can call your PCP’s office and make an appointment. Your PCP is familiar with you and your medical history. He or she can help you with health concerns that are not putting you in immediate danger.

Examples of non-emergencies:

• Colds, cough, flu, mild fever
• Sore throat
• Upset stomach
• Sprain or strain
• Minor cuts, bruises or burns
• Nausea, vomiting or diarrhea
• Insect sting
• Joint and back pain
• Tooth or dental pain
• Minor asthma attack
• Mild allergic reaction
• Ear infection
• Migraine
• Pink eye
• Urinary tract infection
• Running out of your medicine
• Medication side effects

If your PCP is closed or not available, please consider going to a local in-network urgent care clinic for issues that are non-emergencies. Your Care Coordinator can assist you with finding an urgent care clinic in your area.

Behavioral Health Crisis
If you are experiencing a behavioral health crisis, call our behavioral health crisis line and we will find a crisis provider for you. If your symptoms include thoughts about harming yourself or someone else, call 911 or get to the closest emergency room right away.

Behavioral Health Crisis Line (available 24/7/365)
988

There are some treatments, services and drugs that require approval from us before you can get them. This is called a prior authorization. You or your doctor can ask for a prior authorization. Call Member Services to ask if a service or treatment needs a prior authorization.

After you or your doctor asks us for a prior authorization, we review the request to decide if the treatment is medically needed and right for you. We will let you know if the request is approved within 14 calendar days. If waiting more than 14 days could seriously harm your health, your doctor can ask us to do an expedited review. If your doctor asks for an expedited review, we will let you know if the request is approved within 3 calendar days, or as quickly as your health condition requires.

If you disagree with our decision, you can file an appeal. You can read more about how to do that on this page. Look in your Member Handbook for more information about prior authorizations.

What is an appeal?

An appeal is a way for you to challenge an adverse benefit determination (a denial or reduction in benefits) made by Molina Healthcare (Molina) if you think we made a mistake. You can ask us to change our decision by filing an appeal.

What is a grievance?

A grievance is a dissatisfaction you have with us or one of the providers or pharmacies in the Molina network. This includes a dissatisfaction with the quality of your care.

How do I file an appeal?
If you are not satisfied with a decision we made, you have 60 calendar days to file an appeal. You can file the appeal yourself or ask someone to file the appeal for you. You can call Member Services if you need help filing an appeal.

You can file an appeal by phone or in writing. You can send your appeal as a standard appeal or an expedited (fast) request.

Check your Member Handbook for complete instructions on how to file an appeal. Learn More

How do I file a grievance?
You can file a grievance at any time. There are different types of grievances. An internal grievance is about a dissatisfaction  you want to file with Molina. To file an internal grievance, you can call Member Services or send the grievance to us in writing.

An external grievance is about a dissatisfaction you have that  you make to the state or a state agency about Molina or one of our network providers or pharmacies.

Check your Member Handbook for complete instructions on how to file a grievance. Learn More

Molina Healthcare’s Fraud and Abuse Plan benefits Molina, its employees, members, providers, payers and regulators by increasing efficiency, reducing waste, and improving the quality of services.

Molina Healthcare takes the prevention, detection, and investigation of fraud and abuse seriously,

and complies with state and federal laws. Molina Healthcare investigates all suspected cases of fraud and abuse and promptly reports to government agencies when appropriate. Molina Healthcare takes the appropriate disciplinary action, including but not limited to, termination of employment, termination of provider status, and/or termination of membership. You can report potential fraud, waste and abuse without giving us your name.

To report suspected Medicaid fraud, contact

Molina Healthcare AlertLine at: Toll free, (866) 606-3889 (TTY: 711)

Or

Complete a report form online at: MolinaHealthcare.alertline.com

Definitions:

“Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. (42 CFR §455.2)

“Fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit for them or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR § 455.2)

Here are some ways you can help stop fraud:

• Don’t give your Molina Healthcare ID card, Medical ID Card, or ID number to anyone other than a health care provider, a clinic, or hospital, and only when receiving care.
• Never let anyone borrow your Molina Healthcare ID Card.
• Never sign a blank insurance form.
• Be careful about giving out your social security number.

If you have not gotten your Member ID card, or your card is damaged, lost or stolen, call Member Services right away and we will send you a new card.

Member Services

• (844) 862-4543 (TTY: 711)

You can also log in to the Member Portal and request a new Member ID card under “Member ID Card”.

It is important for you to take your Health Risk Assessment (HRA). Your answers will help us understand your needs and allow us to provide you with the best level of care.

An individualized care plan includes the types of health services that you need and how you will get them, as well as your personal goals for your health. It’s based on your Health Risk Assessment (HRA) and individual needs and goals. After you complete your HRA, your care team will talk to you about what kind of healthcare you need. They will also ask you about your goals and preferences.

Together, you and your care team will make a personalized care plan, specific to your needs. Your care team will work with you to update your care plan when your healthcare needs change, and at least once per year. You can find your care plan, if applicable, in your Health Record in the Member Portal.

Do you need a ride to your healthcare appointments? We can get you there! Please contact Superior Medical Transport to schedule a ride:

• You can use your Superior Medical Transport member portal: Y