How to File an Appeal
Appeals
If you receive a denial letter and do not like the choice we made, you can file an appeal. An appeal is a request to review an action or denial. An action is any denial that is:
- Limited
- Reduced
- Suspended
- Terminated, or
- Payment is denied
Filing an Appeal
All appeals must be filed in 60 days from the day of the denial. If you call, you may be asked to send more information in writing.
To file your appeal you can:
- Call Member Services
- Write a letter
- Fill out the
Member Appeal Request Form
Mail the letter or fax the form to:
Affinity by Molina Healthcare
Attention: Grievance & Appeals Department
2900 Exterior Street
Suite 202
Bronx, New York 10463
(800) 223-7242
Fax: (718) 536-3358
If you need a copy of the
- Your first and last name
- Your signature
- Date of Birth
- Date
- Your Molina ID number. It is on the front of your Member ID Card
- Your address and telephone number
- Explain the problem
We try to solve your appeal right away. Your appeal is looked at by the Grievance and Appeals Department. A letter is mailed to you in 15 days. This letter lets you know we have your appeal. The reviewer will note and take care of your appeal. The reviewer will work with the right departments to solve your appeal. For standard appeals, we will mail our decision in 30 days from the day we received it. For expedited appeals, we will mail our decision in 3 business days from the day we receive it.
In order to be fair, cases will not be looked at by the same person that made the first decision. All appeals about medical services are reviewed by our medical staff.
Expedited or Rushed Appeals
An expedited or a rushed appeal is when waiting for a regular appeal may risk your life or health. All rushed appeals will be solved in 2 business days or as quickly as your health condition requires but no more than 3 business days from the date of the request for a rushed appeal.
Filing a Rushed Appeal
You, your doctor or someone else, with your approval in writing, may call or write to ask for an appeal to be rushed. We can help you with this. Molina Healthcare will decide if your appeal meets a rushed review.
The decision is made in 2 business days from the time we received your appeal or as quickly as your health condition required, but no more than 3 business days. We will let you know our answer in writing. If the decision is to deny the appeal, you will be notified by mail within 24 hours of the decision. If the decision is an approval, a letter will be mailed to you in two (2) days from the time the decision was made.
An expedited or rushed appeal can be filed using the same process as a standard appeal.
Continuing benefits during appeal process
If you would like to go on with your benefits while you are appealing you must:
- Let us know in (10) days from the date on the denial letter.
- Let us know in (10) days after the effective date of the action, whichever is later.
The appeal must be about an action that was denied. An action is any denial that is:
- Limited
- Reduced
- Suspended
- Terminated of a treatment that was approved before
The service must have been asked for by an approved doctor
- The approval cannot have ended.
- If you request an extension of benefits.
If we decide to go on with your benefits, your benefits will go on until:
- You withdraw the appeal.
- Ten days have passed from the date of the denial and you have not asked for a Medicaid Fair Hearing.
- The Medicaid Fair hearing makes a decision not in your favor.
- The authorization for the benefits has ended or the limits are met.
If you asked to go on with your benefits and the decision is not in your favor you may have to pay for the services that were given to you. Mail letter, call or fax the request to:
Affinity by Molina Healthcare
Attention: Grievance & Appeals Department
2900 Exterior Street
Suite 202
Bronx, New York 10463
(800) 223-7242
Fax: (718) 536-3358