Molinalogo

We want to give you good care!

Molina Healthcare (Molina) works with our providers to give you good health care. We look at your member benefits and make choices about care based on what you need. We want you to know:

• We do not reward providers to deny care.
• We do not reward staff or other people to deny care or give you less care.
• We do not pay extra money to providers or our staff members to deny tests or treatments that you need to get better or stay healthy.

Members who have a concern about their health care can contact Member Services at (844)862-4543 (TTY:711)

• Our staff are here to take calls Monday through Friday between 8 a.m. – 5 p.m. MST If members call after 5 p.m. or on a holiday they can leave a message and their phone number. Our staff will return the call in a timely manner, in no more than one business day.
• All calls are toll free.
• There are nurses you can talk to about your healthcare questions and concerns.  They are available 24/7, 365 days a year. Nurse Advice Line. (833)-965-1558 (TTY:711). 
• A bilingual staff member or interpreter is available for members.

Primary Care

A Primary Care (PCP) is a doctor who helps you when you are sick and can also help you stay healthy. You may think you do not need a doctor until you are sick. This is not the best time for you to meet your doctor for the first time. Contact your Primary Care to make your first appointment. This first visit will help your PCP get to know you and help you stay well. Please contact Member Services if you need help getting an appointment.

Go to your PCP for:

• Check-ups
• Vaccines
• Illnesses
• Specialist visits
• Hospital visits

.  Routine checkups help your PCP detect and treat medical conditions early. If you need to see a specialist, your PCP will refer you to one. Your PCP works with you to keep you and your family healthy.

Specialty Care

Your PCP will take care of most of your needs. There may be times when you will need to see a specialist. Your PCP will refer you to a specialist that can treat your specific condition. We call this a referral.

Examples of specialists are:

• Cardiologists
• ENT physicians (Ear, Nose & Throat)
• Neurologists
• Allergists

There are some providers that do need referrals. For example:

• Gynecologists
• Dermatologists
• Psychologists

It is a good idea to check with Member Services to see if the provider is in Molina’s network. You can also use our provider look-up tool., If you need to see a provider or specialist that is not in Molina’s network, contact your PCP to get prior approval from Molina.

Out of Network Services

If a Molina provider is unable to provide a member with necessary and covered services, Molina must cover the needed services through an out-of-network provider. The cost to members should be no greater than it would be if the provider were in Molina ’s network. This must be done in a timely manner for as long as Molina is unable to provide the service.

After Hours Care

If you need care after normal business hours, contact your PCP. All PCPs have coverage for their patients 24 hours a day, 7 days a week. Your PCP may have an answering service where someone can help you with your medical issue or they can contact your PCP to discuss your options for care. Sometimes your PCP may have another PCP cover for them either after hours or if your PCP is out of the office. They could give you advice over the phone and sometimes prescribe a medication. You might be asked to visit the PCP or be sent to an urgent care center.

Molina also has a Nurse Advice Line with highly trained nurses. They can help you decide if you or your child should seek medical attention right away. You can contact the Nurse Advice Line at (833)965-1558 (tty:711) and talk to a nurse. 24 hours a day, 7 days a week.

If you feel this is an emergency, contact 911 or go to the nearest emergency room.

Emergency Care

An emergency is a medical problem that needs to be treated immediately. We cover emergencies wherever you are. You do not have to contact Molina for approval in an emergency. Contact 911 or go to the nearest emergency room. This includes a facility that is not part of Molina. You can get emergency care 24 hours a day, 7 days a week.

Some examples of emergency are:

• Miscarriage or pregnancy problems
• Seizures or convulsions
• Unusual or excessive bleeding
• Unconsciousness
• Overdose/Poison
• Severe pain
• Severe burns
• Trouble breathing
• Chest pains

Please carry your Member ID Card with you. If you are told you need to stay in the hospital, make sure the hospital contacts Molina. If you are asked to stay in a hospital that is not part of Molina’s network, we will transfer you to a hospital that is part of Molina‘s network as soon as you are well enough to be moved. If the emergency room doctor decides that you do not have to stay but you decide to stay, you may be responsible for the cost of your stay. Once you leave the ER and are instructed to follow up with your PCP, please schedule an appointment with your PCP. If you need help scheduling an appointment, please contact Member Services.

If you are not sure if you need emergency care, contact your PCP or our 24-Hour Nurse Advice Line toll-free. The Nurse Advice Line is staffed by registered nurses (RNs). You can contact the Nurse Advice Line 24 hours a day, 7 days a week. (833)-965-1558 (TTY:711). 

Hospital emergency rooms are only for real emergencies. These are not good places to get non-emergency care. They are often very busy and must care first for those whose lives are in danger. Please do not go to a hospital emergency room if your condition is not an emergency.

Out of Area Care

If you are away from Molina ’s service areas and need emergency care, go to the nearest emergency room for care. Please contact Molina within 24 hours or as soon as you can.  When you are away from Molina ’s service area, only emergency care is covered.. No services are covered outside the United States.

Urgent Care

Urgent care services are for conditions that need attention right away. You should contact your PCP for urgent care services. Your PCP may send you to an after-hours clinic or an urgent care center when the PCP’s office is closed.

Some examples of urgent services are:

• Minor injuries
• Minor illnesses
• High fever for children or elderly
• Simple fractures
• Flu
• Eye injuries
• Insect bites

An urgent care center is not an emergency room. If you are not sure if you need to go to the ER, contact your PCP or Molina ’s 24-hour Nurse Advice Line. Your PCP or our nurses can help you decide what to do. You can find the number to our 24-Hour Nurse Advice Line toll-free here. (833)-965-1558 (TTY:711).

Second Opinions

You have the right to request a second opinion from a qualified health care professional within Molina’s network or we can arrange for you to obtain one outside of our network at no cost. Please contact Member Services to request the second opinion.

If the request is urgent and serious:

• Molina will respond within one (1) day.
• The second opinion will be given within (72) hours.

Reasons why second opinions are needed:

• You are not sure you need the treatment the doctor suggests.
• You are not sure of the doctor’s diagnosis.
• You have a complex problem.
• Your doctor is not sure of a correct diagnosis.
• You have complex symptoms.
• You have followed the doctor’s care plan but have not improved.
• You have talked with your doctor about your concerns but still are not satisfied.

If a second opinion is approved, you will not have to pay for the services. The doctor that you see for a second opinion will send a written report to you and your PCP.

Language Assistance

Interpreter services are free to all members. To ask for an interpreter, please contact Member Services. Interpreter can help you:

• Make an appointment.
• Talk with your doctor or nurse.
• Get emergency care.
• File a complaint, grievance, or appeal.
• Get help from a pharmacist about taking medicine.

Interpreter services are free to all members. To ask for an interpreter, contact Member Services.

If you have an appointment, your doctor can help you find an interpreter.

If you are hearing or sight impaired, Molina can help you. It may take some time, please do not hang up.

• We offer our Member Handbook in braille. Please contact Member Services to request one.
• If you are hard of hearing, contact our TTY line at 711. 

The Quality Improvement Program:

• Checks providers to be sure you have access to a qualified health care team.
• Reviews and takes action when there is an issue with the quality of care that has been provided.
• Promotes safety in health care through education for our members and our providers.
• Provides a Grow and Stay Healthy Guide to help members know what services are needed and when.
• Provides a Guide to Accessing Quality Health Care  to help members access our programs and services.
• Evaluates the quality of health care through HEDIS^® (Healthcare Effectiveness Data and Information Set).
  • These scores tell us when you have received the type of care you need. The scores look at how often members receive services such as flu shots, immunizations, eye tests, cholesterol tests and prenatal care for members who are pregnant.
  • Check out our HEDIS^® rates and results.
• Surveys members’ satisfaction with care. One type of survey is called CAHPS^® (Consumer Assessment of Healthcare Providers and Systems).
  • This tells us if you are happy with your care and your provider. It also tells us what we can make better for our members. Some things are getting the right type of appointment at the right time and having enough providers to take care of your needs.
  • Check out our CAHPS^® results.

^*You may request printed copies of all content posted on our website.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Healthcare Effectiveness Data and Information Set (HEDIS^®)

Molina Healthcare (Molina) uses the HEDIS^® tool each year as a way to measure quality. This is done by looking at the type of care and services provided. HEDIS^® is maintained by the National Committee for Quality Assurance (NCQA). This allows the review of certain aspects of care. This includes clinical and non-clinical care. It also shows where plans can improve care and service. Molina ’s goal is to be better than 75 percent of Medicaid health plans in the nation who report their results to NCQA.

HEDIS^® Annual Trends

If you have any questions or would like additional information about HEDIS^®, please contact Member Services.

*You may request printed copies of all content posted on our website by calling the Member Services phone number on your member ID card.

HEDIS^® is a Registered Trademark of the National Committee for Quality Assurance.

Consumer Assessment of Healthcare Providers and Systems (CAHPS^®)

The CAHPS^® is a program managed by the U.S. Agency for Healthcare Research and Quality (AHRQ). CAHPS surveys are used by the National Committee for Quality Assurance (NCQA), a non-profit group that wants to improve health care quality. Molina members are surveyed each year by an independent organization using the CAHPS^® Adult and Child Medicaid Health Plan surveys. These surveys measure how happy members are with their health plan and the care received from doctors. Molina’s goal is to be better than 75 percent of Medicaid health plans in the nation who report their results to NCQA.

Detailed results can be found by clicking below:

• CAHPS^® Annual Trends

If you have any questions or would like additional information about CAHPS® please contact Member Services. 

*You may ask for copies of all content on our website by calling the Member Services phone number on your member ID card.

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Molina Healthcare (Molina) wants you and your family to be safe and healthy. We have a Patient Safety program to help us meet this goal. This program gives you the safety facts, so you can make better health care choices. Here are a few of the things we do to improve safety:

• Keep track of our members’ complaints about safety problems in their provider’s office or hospital.
• Look at reports from groups that check hospital safety. Reports tell us about things such as if there was enough staff in the intensive care unit (ICU), use of computer drug orders and so forth.
• Help members coordinate care when moving from one setting to another (e.g., hospital to home).
• Educating members about what to ask when you see a doctor.

Groups that check safety:

• Leap Frog Quality Index Ratings
• The Joint Commission National Patient Safety Goal Ratings

Molina members can look at these websites:

• To see what hospitals are doing to be safer.
• To know what to look for when they pick a provider or a hospital.
• Get information about programs and services for members with problems like diabetes and asthma.

^*You may request printed copies of all content posted on our website.

Molina Healthcare (Molina) uses a medical review process to rate:

• A new drug
• Medical devices
• Medical rules or procedures
• Surgical rules or procedures
• Behavioral health rules or procedures
• Therapy

We want to make sure that new health care developments are safe and helpful to members. The goals of this process are:

• To review and update coverage choices as new scientific proofs are found.
• To review cases in order to decide if it is or is not = service we should cover.

Molina may deny a drug, device, protocol, procedure, or other therapy that is new. We might say it is not medically necessary. If this happens, you can ask us why. You or your PCP can ask for this information. You can have copies of all the rules and procedures we used to make the decision. For information on this process, call Member Services. 

These rights and responsibilities are posted in doctors’ offices. They are also posted at

www.WelcomeToMolina.com/NM. You or your legal guardians have a right to get information about:

1. Molina, its policies and procedures about products, services, contracted providers, grievance procedures, benefits provided and your rights and responsibilities.
2. You have a right to be treated with courtesy and kindness and with respect and recognition of your dignity, need, and right to privacy.
3. You or your legal guardians have a right to choose a PCP within the limits of the covered benefits and plan network and the right to refuse care of specific practitioners or to notify the provider if changes need to be made. You or your legal guardians have a right to get from your providers in terms that you or your legal guardian(s)understand, an explanation of your complete medical condition and recommended treatment, risk(s) of the treatment, expected results, and reasonable medical alternatives, regardless of the health care insurers or Molina’s position on treatment options. If you are not able to understand the information, the explanation shall be provided to your next of kin, guardian, agent, or surrogate,if available, and noted on the medical record.
4. You have a right to get health care services in a non-discriminatory fashion.
5. If you do not speak English as your first language, you have the right to get translation services at no cost.
6. If you have a disability, you have the right to get information in an alternative format in compliance with the Americans with Disabilities Act.
7. You or your legal guardians have a right to participate with your health care providers in decision- making in all aspects of your health care, including the treatment plan development, acceptable treatments, and the right to refuse treatment.
8. You or your legal guardians have the right to informed consent.
9. You or your legal guardians have the right to choose a surrogate decision maker to be involved, as appropriate, and to help with care decisions.
10. You or your legal guardians have the right to get a second opinion by another provider when you need more information about a recommended treatment or believe the provider is not authorizing the care requested.
11. You have a right to an open and honest discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
12. You or your legal guardians have a right to voice complaints, grievances, or appeals about Molina, the handling of complaints, or the care provided and make use of Molina’s complaint process and the State Fair Hearing process after exhausting Molina’s grievance/appeal process, at no cost, without fear of retaliation.
13. You and your legal guardians have a right to file a complaint or appeal with Molina or the State’s Fair Hearing Bureau after exhausting Molina’s grievance/appeal process and to get an answer to those complaints or appeals within a reasonable time.
14. You and your legal guardians have a right to choose from among the available providers within the limits of Molina’s network and its referral and prior authorization requirements.
15. You and your legal guardians have a right to make your decisions known through advance directives about health care decisions (living wills, right-to-die directives, “do not resuscitate” orders) consistent with federal and state laws and regulations.
16. You and your legal guardians have a right to the privacy of medical and financial records kept by Molina and its providers, in accordance with existing law.
17. You and your legal guardians have a right to access your medical records in accordance with the applicable federal and state laws and regulations.
18. You have the opportunity to allow or deny the release of identifiable medical or other information by Molina, except when such release is required by law.
19. You have a right to ask for an amendment to your Protected Health Information (PHI) if the information is believed to be incomplete or wrong.
20. You or your legal guardians have a right to get information about Molina, its health care services, and how to get those services and the network practitioners/providers.
21. You or your legal guardians have a right to be given information about Molina’s policies and procedures regarding products, services, providers, appeal procedures, allowing use of your medical information, allowing access to your medical records, and protecting access to your medical information and other information about Molina and the benefits provided.
22. You or your legal guardians have a right to know, upon request, of financial arrangements or provisions between Molina and its providers, which may limit referral or treatment options or limit the services offered.
23. You or your legal guardians have a right to be free from harassment by Molina or its network providers concerning contractual disputes between Molina and providers.
24. You or your legal guardians have a right to available and accessible services when medically necessary as determined by the PCP or treating provider in consultation with Molina. This is for 24 hours per day, 7 days per week for urgent or emergency care services and for other health care services as defined by the contract or evidence of coverage.
25. You have the right to adequate access to qualified health professionals near where you live or work, within the service area of Molina.
26. You have a right to affordable health care, with limits on out-of-pocket expenses, including the right to get care from a non-participating provider and an explanation of your financial responsibility when services are given by a non-participating provider or given without required pre-authorization.
27. You or your legal guardians have a right to prompt notification of termination or changes in benefits, services, or provider network.
28. You have the right to continue an ongoing course of treatment for a period of at least thirty 30 days . This shall apply if your provider leaves the provider network or if a new member’s provider is not in the provider network.
29. You have the right to make recommendations about Molina’s rights and responsibilities.
30. You have a right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation, as specified in other federal regulations on the use of restraints and seclusion.
31. You and your legal guardians have the right to select an MCO and exercise switch enrollment rights without threats or harassment.
32. You have a right to detailed information about coverage, maximum benefits, and exclusions of specific conditions, ailments, or disorders, including restricted benefits and all requirements that you must follow for prior approval and utilization review.
33. You or your legal guardians have all the rights afforded by law, rule, or regulation as a patient in a licensed health care facility, including the right to refuse medication and treatment after consequences of this decision have been explained in language you understand.
34. You and your legal guardians have the right to a complete explanation of why care is denied, an opportunity to appeal the decision to Molina’s internal review and the right to ask for the HCA’s help as applicable.
35. You and your legal guardians have the right to get information, when you ask, that HCA determines is important during your first contact with the MCO. This information can include a request for information about the MCO’s structure, operation, and/or practitioners’ or senior staff’s incentive plans.
36. You or your legal guardian shall be free to exercise your rights, and exercising those rights will not result in adverse treatment of you or your legal guardian.

1. You and your legal guardians have a responsibility to give to the extent possible, information that Molina and its providers need in order to care for you.
2. You and your legal guardians have a responsibility to understand your health problems and to help in developing treatment goals that everyone can agree to.
3. You and your legal guardians have a responsibility to follow the plans and instructions for care that they have agreed on with your provider or to notify providers if changes are requested.
4. You or your legal guardians have a responsibility to keep, reschedule or cancel an appointment rather than to simply not show up.
5. You and your legal guardians have a responsibility to look at the Member Handbook and, if there are questions, call the Member Service for details on benefits, limits and exclusions.The Member Services telephone number is on your ID card.
6. You and your legal guardians have a responsibility to follow Molina’s policies, procedures and instructions for getting services and care.
7. If you or your legal guardian sees a self-referred specialist or provider without following Molina procedures and Molina denies the service, the provider may bill you.
8. You and your legal guardians have a responsibility to show your ID card each time you go for medical care and to tell Molina right away of any loss or theft of your ID card.
9. You or your legal guardians have a responsibility to tell a participating provider of their coverage with Molina at the time of service. You may have to pay for services if you do not tell the participating provider of your coverage.
10. You and your legal guardians have a responsibility to pay for all services you get before the effective date with Molina and after the termination or cancellation of coverage with Molina if you do not have insurance. covered. If you are covered with Fee-for-Service Medicaid, another MCO or another insurance company before the effective date or after termination or cancellation with Molina should tell the provider about your other coverage.
11. You or your legal guardians have a responsibility to tell the ISD Caseworker if there is a change in name, address, telephone number or changes in your family.
12. You and your legal guardians have a responsibility to tell HCA and Molina if you get other medical coverage.
13. You and your legal guardians have a responsibility to pay for all co-pays and/or co-insurance at the time services are rendered.

^*You may request printed copies of all content posted on our website. You can do so by calling Member Services at (844) 862-4543 (TTY:711). 

We hope you are happy with the care and services you receive. If you are not, we want you to know you have options. You, or someone you choose to help you may file an appeal of an Adverse Determination or a grievance by phone, through your Member Portal on MyMolina.com, email or in writing. Molina can help you complete forms to file a grievance or an appeal free of charge. If you need help, please call Member Services at our toll-free number (844) 862-4543 (TTY: 711). We have people to help you Monday through Friday,8:00 a.m. - 5:00 p.m. MST. Translation services are also available if needed. Molina will not treat you differently for filing an appeal or grievance.

How to file a grievance

You may file a grievance at any time. You may choose someone to help you file a grievance; this is called an authorized representative. You must give written consent to allow someone to file a grievance on your behalf.

You can file a grievance in writing, or over the phone by calling Member Services at (844)-862-4543 (TTY: 711). Or any of the following methods:

• Using the Member Portal at MyMolina.com
• By mailing to:
  Molina Healthcare of New Mexico, Inc.
  P.O. Box 182273
  Chattanooga, TN 37422
• By faxing to: 1-505-342-0583
• Or by email: MNM.Medicaid.MemberAppealsandGrievances@molinahealthcare.com

What to expect when you file a grievance

You will not be treated differently for filing a grievance. When we get your grievance, we will send you a letter within 5 business days letting you know that we got it.  We will let you know in writing our decision about your grievance within 30 calendar days from the day we got your grievance. If we need additional time to make our decision, a 14 calendar-day extension may be requested. If additional time is needed, we will let you know by phone or in writing within 2 days explaining why it is in your best interest. You may also request an extension if you need more time to support your grievance.

Appeals

You may request an appeal for Molina to review a decision that we made about a service that was denied, reduced, or limited. Some examples of appeals would be:

•   Denial in whole or part of a requested service

•   Stop a service that was previously approved.

A denial is when we do not approve or pay for a service that either you or your doctor asked for. When we deny a service, we will send you a letter telling you why we denied the requested service. This letter is the official notice of our decision and is called an “Adverse Benefit Determination.” It will let you know your rights and information about how to request an appeal.

How to file an appeal

You must send your appeal within 60 calendar days of the date of Molina’s denial letter. You, your authorized representative, or provider on your behalf and with your written consent can appeal the decision. If you need help filing your appeal, you can call Molina Member Services and we will help you complete the steps for filing an appeal.

You can appeal our decision in writing, or over the phone by calling Member Services at (844)-862-4543 (TTY: 711). Or any of the following methods:

• Using the Member Portal at MyMolina.com
• By mailing to:
  Molina Healthcare of New Mexico, Inc.
  P.O. Box 182273
  Chattanooga, TN 37422
• By faxing to: 1-505-342-0583
• Or by email: MNM.Medicaid.MemberAppealsandGrievances@molinahealthcare.com

An appeal form and authorized representative form can be found in your denial letter and online at Molinahealthcare.com. Molina offers only one (1) level of appeal for members.

What to expect when you file an appeal

You will not be treated differently for filing an appeal. You will receive a letter within 5 business days letting you know that we received your appeal. You will be notified of our decision within 30 calendar days for a standard appeal. We may request an extension of 14 calendar days if we feel it is in your best interest. We will send you a letter within two (2) days notifying you of the need for the extension, if you disagree with our decision to extend your appeal, you have the right to file a grievance.

If waiting 30 days will harm your health or life, you can ask for a fast (expedited) appeal. We will make a decision within 72 hours or sooner.  If the request does not need to be completed in 72 hours, we will notify you in writing and will complete your appeal in the standard 30 days.

If Molina fails to resolve your appeal and provide notice within the required timeframe above, then your appeal with Molina is considered to be exhausted and you may request a Fair Hearing.

Fair Hearings

If you are unhappy with our decision of your appeal, you can ask for a Fair Hearing. You must first complete your appeal with Molina before you ask for a Fair Hearing. You, your authorized representative, or your doctor on your behalf with your written consent can request the Fair Hearing. You must send your request within 90 calendar days from the 

date on the letter from Molina notifying you of our decision.

You can make a request to the New Mexico Health Care Authority (HCA) for a Fair Hearing in writing, in person or by phone. If you need help requesting a Fair Hearing or want to file by phone you can call HCA Office of Fair Hearings at (505) 476-6213

To file a Fair Hearing in writing, please send requests to:

Office of Fair Hearings
P.O. Box 2348
Sante Fe, NM 87504-2348

Or Call:

In Santa Fe, call (505) 476-6213
Toll Free: (800) 432-6217, Option 6
Fax: (505) 476-6215
Email: HSD-FairHearings@state.nm.us

Continuing Services during an Appeal or Fair Hearing

You may request a continuation of benefits while your appeal with the Office of Fair Hearing is pending, You must request a continuation of benefits within 10 calendar days from the date we mailed the Adverse Benefit Determination (the effective date of the notice) and all of the following steps were met:

•   You filed the request for an appeal within 60 calendar days from the notice from Molina denying your service request.

•   The appeal or Fair Hearing request is related to the termination, suspension or reduction of services that were previously authorized for you.

•   The services were requested by an authorized Molina doctor.

•   The period covered by the original authorization has not ended.

If the above are met and you request a continuation of benefits, your benefits may be continued until one of the following occurs:

•   You ask to stop the appeal or Fair Hearing.

•   You do not request a Fair Hearing within 10 days from the date of Molina’s letter notifying you of our decision.

•     The authorization for services expires, or service authorization limits are met.

•     A Fair Hearing decision is to deny your request.

Note: IF you keep getting a service during the appeal process or Fair Hearing and the appeal is denied, you may have to pay for the services you received.

You can fax or write to file a complaint or appeal or call the complaint and appeal phone numbers.

They are here 24 hours a day, 7 days a week.
File by mail:
Molina Healthcare of New Mexico, Inc.
Attn: Appeals & Grievance Department
PO Box 182273
Chattanooga, TN 37422

File by phone:
Member Services at (844) 862-4543 (TTY: 711)

File with your member portal:
MyMolina.com

Who can file a complaint or appeal?

You can file for yourself or someone can file for you, such as:

• A legal guardian if you are incapacitated
• Someone of your choice if you approve in writing
• Your provider if you approve in writing

You can speak for yourself in a complaint, appeal or Fair Hearing. You also have the right to have another person speak for you. You have the right to have legal counsel as well.

You must pay for the cost of being represented. Molina will let you, your representative, or your estate representative be parties to an appeal.

Filing a complaint or appeal will not change the way you are treated. Asking for a Fair Hearing will not change the way Molina treats you. It will not change how Molina’s network providers or the Health Care Authority (HCA) treats you.

Everything about your complaint or appeal is private. We do not give out your information about a complaint. We cannot do this without your approval in writing unless we are required by law. A complaint can be filed at any time from the date of the dissatisfaction. An appeal must be filed within sixty (60) calendar days of receiving notice of the Adverse Benefit Determination.

We want to give you the best care possible. Call Member Services at (844) 862-4543 (TTY: 711). If you are having problems. We want to fix the problem. Member Services can help if you need help in another language. We will help you with the translation service. The appeals team can help you with the process. Let us know if you need help making a written request. We try to fix issues as fast as we can. If the issue cannot be taken care of on the same day we get it, a formal grievance or appeal process will take place. There will be a careful review.

A health care professional with suitable clinical experience will take part in the review of medically related complaints or appeals. Formal complaints or appeals are normally resolved within thirty (30) calendar days. We will ask for more time if it is needed. An extension of up to fourteen (14) calendar days can be given if you ask for it. An extension can be given by the Health Care Authority (HCA) to Molina Healthcare. We will tell you if there is a delay.

A written decision will be made for all formal complaint and appeal requests. The written response to a complaint will have the:

• Reason for the complaint

• Information used in the review

• Findings based on the review

• Outcome of the complaint

The written response for an appeal will have the:

• Reason for the appeal.

• Result of the appeal resolution

• Date the appeal was completed.

If the appeal results in a denial, the written notice will have the:

• Reason for the action being taken by Molina.

• Specific references and citations supporting the decision as taken from the Medical Assistance Division (MAD) and/or Molina policies and procedures.

• Information on your right to ask for a Fair Hearing of an appeal denial within 90 calendar days of the final decision. You are not responsible for the cost of the State Fair Hearing.

• Right to ask for benefits while the hearing is pending. We will let you know how to ask for this.

• Information that you may have to pay for the cost of benefits. This is if the hearing decision upholds the denial.

How to request a State Fair Hearing

You have a right to ask for a State Fair Hearing. You can do this when Molina decides to modify, change, suspend, reduce or deny a requested good or service. You do not have to pay for the cost of this hearing. You and/or your spokesperson will work with Molina in the hearing.

You can ask for a State Fair Hearing after you have exhausted Molina’s internal grievance/appeal process. You ask the HCA Hearings Bureau for the appeal. You have to do this within 90 calendar days of the final Molina decision. You can contact the HCA Fair Hearings Bureau by writing or calling:

New Mexico Health Care Authority Department

Fair Hearings Bureau

P.O. Box 2348

Santa Fe, NM 87504

Email: HSD-FairHearings@state.nm.us

Call: (505) 476-6213 (TTY: 711) or (800) 432-6217 OPTION 6

Consolidated Customer Service Center: (800) 283-4465

Fax: (505) 476-6215

If you ask Molina for a State Fair Hearing, we will send the request to HCA. We cannot ask for a State Fair Hearing for you. Your provider cannot ask for a State Fair Hearing for you. This does not require Molina to start any treatment or services. This does not require Molina to increase the level of any treatment or services. You may have to pay the cost of treatment or services you get while the State Fair Hearing is pending. You will have to pay the cost of services you get if the decision is upheld at the hearing.