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The rest of this section has separate parts that tell you how to make an appeal and/or complaint in each of the following situations:

1. Appeals about what we will cover for you or what we will pay for. If Molina Dual Options or your doctor or another plan provider has refused to give you a service you think is covered, you can make an appeal. If we have refused to pay for a service you think is covered for you, you can make an appeal. If you have been receiving a covered service, and you think that service is being reduced or ending too soon, you can make an appeal. When you file an appeal, you are asking us to reconsider and change a decision we have made about what services we will cover for you (which includes whether we will pay for your care or how much we will pay).

2. Appeals about your Part D prescription drug benefits that we will cover or pay for. If Molina Dual Options refused to give you a Part D prescription drug benefit that you think is covered, you can request an appeal. If we have refused to pay for a Part D prescription drug that you have already received and you believe that it is covered, you can make an appeal. If you have been receiving a Part D prescription drug, and you think its coverage is being reduced or ending too soon, you can make an appeal. When you file an appeal, you are asking us to reconsider and change a decision we have made about what Part D prescription drug we will cover for you (which includes whether we will pay for a Part D prescription drug that you have already received, or how much we will pay). The rules that apply to appeals of drug coverage are different than the rules that apply to your health benefits. Be sure to read the Member Handbook so that you clearly understand the difference.

3. Appeal if you think you are being discharged from the hospital too soon. There is a special type of appeal that applies only to hospital discharges. If you think our coverage of your hospital stay is ending too soon, you can appeal directly and immediately to your state Quality Improvement Organization (QIO). Your state QIO is a group of health professionals that are paid to handle this type of appeal from Dual Options patients. If you make this type of appeal, your stay may be covered during the time period the QIO uses to make its determination. You must contact the Quality Improvement Organization no later than noon of the day after you got the written notice telling you when we will stop covering your care.

4. Appeal if you think your coverage for Skilled Nursing Facility (SNF), Home Health (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services is ending too soon. There is another special type of appeal that applies only when coverage will end for SNF, HHA or CORF services. If you think your coverage is ending too soon, you can appeal directly and immediately to KEPRO, which is the Quality Improvement Organization in your state. If you make this type of appeal, your stay may be covered during the time period the QIO uses to make its determination. You must act very quickly to make this type of appeal, and it will be decided quickly.

5. Complaints about any other type of problem you have with Molina Dual Options or one of our plan providers. If you want to make a complaint about any type of problem other than those that are listed above, a grievance is the type of complaint you would make. For example, you would file a complaint to address problems with the quality or timeliness of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office. Generally, you would file the complaint with Molina Dual Options. But for many problems related to quality of care you get from plan providers, you can also complain to the QIO in your state.

This part explains what you can do if you have problems getting the medical care you believe we should provide. We use the word "provide" in a general way to include such things as authorizing care, paying for care, arranging for someone to provide care, or continuing to provide a medical treatment you have been getting. Problems getting the medical care you believe we should provide include the following situations:

- If you are not getting the care you want, and you believe that this care is covered by Molina Dual Options.
- If we will not authorize the medical treatment your doctor or other medical provider wants to give you, and you believe that this treatment is covered by Molina Dual Options.
- If you are being told that coverage for a treatment or service you have been getting will be reduced or stopped, and you feel that this could harm your health.
- If you have received care that you believe was covered by Molina Dual Options while you were a member, but we have refused to pay for this care.

Six possible steps for requesting care or payment from Molina Dual Options: If you are having a problem getting care or payment for care, there are six possible steps you can take to ask for the care or payment you want from us. At each step, your request is considered and a decision is made. If you are unhappy with the decision, you may be able to take another step if you want to continue requesting the care or payment.

In Steps 1 and 2, you make your request directly to us. We review it and give you our decision. In Steps 3 through 6, people in organizations that are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Healthy Connections Prime program or the federal court system.
The six possible steps are summarized below (they are covered in more detail in the Member Handbook).

Step 1: The initial decision by Molina Dual Options
The starting point is when we make a coverage decision about your medical care or about paying for care you have already received. When we make a coverage decision, we are giving our interpretation of how the benefits and services that are covered for members of Molina Dual Options apply to your specific situation. As explained in the Member Handbook, you can ask for a fast coverage decision if you have a request for medical care that needs to be decided more quickly than the standard time frame.

Step 2: How to make a Level 1 Appeal to Molina Dual Options
You may ask us to review our coverage decision, even if only part of our decision is not what you requested. When we receive your request to review the coverage decision, we give the request to people at our organization who were not involved in making the coverage decision. This helps ensure that we will give your request a fresh look.

Step 3: Review of your request if we turn down your Level 1 Appeal
If we turn down part or all of your request and it is related to a Medicare service or item, in Step 2, we are required to send your request for a Level 2 Appeal with an Independent Review Entity (IRE) that has a contract with the federal government and is not part of Molina Dual Options. This organization will review your request and make a decision about whether we must give you the care or payment you want.

My problem is about a Healthy Connections Medicaid service or item
If we say no to part or all of your Level 1 Appeal for a Medicaid service or item, you can file a Level 2 Appeal with the Division of Appeals and Hearings. You must request the State Fair Hearing within 120 calendar days of the date of our Level 1 decision, unless the Division of Appeals and Hearings extends the deadline for you.

You can ask for a State Fair Hearing by filing your request online at https://msp.scdhhs.gov/appeals

You can also deliver your request in person or fax your request to (803) 255-8206 or write to:

Division of Appeals and Hearings
South Carolina Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206

Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the Independent Review Entity (IRE) or the Division of Appeals and Hearings that reviews your case in Step 3, you may ask for an Administrative Law Court Judge to consider your case and make a decision. The Administrative Law Court Judge works for the federal government. The dollar value of your contested benefit must be at least $180 to be considered in Step 4. Please refer to the Member Handbook Chapter 9 for Medicaid services and items.  

Step 5: Review by a Medicare Appeals Council
If you or we are unhappy with the decision made in Step 4, either of us may be able to ask a Medicare Appeals Council to review your case if you are appealing a Medicare covered services or items. The Medicare Appeals Council is part of the federal department that facilitates the Healthy Connections Prime program.

Step 6: Federal Court
If you or we are unhappy with the decision made by the Medicare Appeals Council in Step 5, either of us may be able to take your case to a Federal Court. The dollar value of your contested medical care must at least $1850 to go to a Federal Court.

For a more detailed explanation of all six steps outlined above, see the Member Handbook.

This explains what you can do if you have problems getting the prescription drugs you believe we should provide. We use the word "provide" in a general way to include such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have been getting. Problems getting a Part D prescription drug that you believe we should provide include the following situations:

- If you are not able to get a prescription drug that you believe may be covered by Molina Dual Options.
- If you have received a Part D prescription drug you believe may be covered by Molina Dual Options while you were a member, but we have refused to pay for the drug.
- If we will not provide or pay for a Part D prescription drug that your doctor has prescribed for you because it is not on our formulary.
- If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped.
- If there is a requirement that you try another drug before we pay for the drug your doctor prescribed, or if there is a limit on the quantity (or dose) of the drug and you disagree with the requirement or dosage limitation.

Six possible steps for requesting a Part D benefit or payment from Molina Dual Options: If you are having a problem getting a Part D benefit or payment for a Part D prescription drug that you have already received, there are six possible steps you can take to ask for the benefit or payment you want from us. At each step, your request is considered and a decision is made. If you are unhappy with the decision, you may be able to take another step if you want to continue requesting the benefit or payment.

In Steps 1 and 2, you make your request directly to us. We review it and give you our decision. In Steps 3 through 6, people in organizations that are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Healthy Connections Prime program or the federal court system.

The six possible steps are summarized below (they are covered in more detail in the Member Handbook).

Step 1: The initial decision by Molina Dual Options
The starting point is when we make an coverage decision about your Part D prescription drug or about paying for Part D drug that you have already received. When we make an coverage decision we are giving our interpretation of how the benefits that are covered for members of Molina Dual Options apply to your specific situation. As explained in the Member Handbook, you can ask for a fast coverage decision if you have a request for benefits that needs to be decided more quickly than the standard time frame.

Step 2: Appealing the initial decision by Molina Dual Options
If you disagree with the decision we make in Step 1, you may ask us to reconsider our decision. This is called an "appeal" or a "request for re-determination." As explained in the Member Handbook, you can ask for a "fast appeal" if your request for benefits needs to be decided more quickly than the standard time frame. After reviewing your appeal, we will decide whether to stay with our original decision, or change this decision and give you the benefit or payment you want.

Step 3: Review of your request if we turn down your Level 1 Appeal
If we turn down part or all of your request and it is related to a Medicare service or item, in Step 2, we are required to send your request for a Level 2 Appeal with an Independent Review Entity (IRE) that has a contract with the federal government and is not part of Molina Dual Options. This organization will review your request and make a decision about whether we must give you the care or payment you want.

My problem is about a Healthy Connections Medicaid service or item
If we say no to part or all of your Level 1 Appeal for a Medicaid service or item, you can file a Level 2 Appeal with the Division of Appeals and Hearings. You must request the State Fair Hearing within 120 calendar days of the date of our Level 1 decision, unless the Division of Appeals and Hearings extends the deadline for you.

You can ask for a State Fair Hearing by filing your request online at https://msp.scdhhs.gov/appeals

You can also deliver your request in person or fax your request to (803) 255-8206 or write to:

Division of Appeals and Hearings
South Carolina Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206

Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the Independent Review Entity (IRE) or the Division of Appeals and Hearings that reviews your case in Step 3, you may ask for an Administrative Law Court Judge to consider your case and make a decision. The Administrative Law Court Judge works for the federal government. The dollar value of your contested benefit must be at least $180 to be considered in Step 4. This review level is for Medicare services only. Please refer to the Member Handbook Chapter 9 for Medicaid services and items.  

Step 5: Review by a Medicare Appeals Council
If you are unhappy with the decision made in Step 4, you may be able to ask the Medicare Appeals Council (MAC) to review your case if you are appealing a Medicare covered services or items. The MAC is part of the federal department that facilitates the Healthy Connections Prime program.

Step 6: Federal Court
If you are unhappy with the decision made by the MAC in Step 5, you may be able to take your case to a Federal Court. The dollar value of your contested benefit must be at least $1850 to go to a Federal Court.

For a more detailed explanation of all six steps outlined above, see the Member Handbook.

When you are hospitalized, you have the right to get all the hospital care covered by Molina Dual Options that is necessary to diagnose and treat your illness or injury. The day you leave the hospital (your "discharge date") is based on when your stay in the hospital is no longer medically necessary. This section explains what to do if you believe that you are being discharged too soon.

Information you should receive during your hospital stay

When you are admitted to the hospital, someone at the hospital should give you a notice called important Message from Medicare about Your Rights. This notice explains:

- Your right to get all medically necessary hospital services covered.
- Your right to know about any decisions that the hospital, your doctor, or anyone else makes about your hospital stay and who will pay for it.
- That your doctor or the hospital may arrange for services you will need after you leave the hospital.
- Your right to appeal a discharge decision.

Review of your hospital discharge by the Quality Improvement Organization

If you think that you are being discharged too soon, ask your health plan to give you a notice called the Detailed Notice of Discharge & Molina Dual Options Appeal Rights. This notice will tell you:

- Why you are being discharged.
- The date that we will stop covering your hospital stay (stop paying our share of your hospital costs).
- What you can do if you think you are being discharged too soon.
- Who to contact for help.
- You (or someone you authorize) may be asked to sign and date this document, to show that you received the notice. Signing the notice does not mean that you agree that you are ready to leave the hospital - it only means that you received the notice. If you do not get the notice after you have said that you think you are being discharged too soon, be sure to ask for it immediately.

You have the right by law to ask for a review of your discharge date. As explained in the Detailed Notice of Discharge & Molina Dual Options Appeal Rights, if you act quickly, you can ask an outside agency called the Quality Improvement Organization to review whether your discharge is medically appropriate.

What is the "Quality Improvement Organization"?

"QIO" stands for Quality Improvement Organization. The QIO is a group of doctors and other health care experts paid by the federal government to check on and help improve the care given to Molina Dual Options patients. They are not part of our health plan or your hospital. There is one QIO in each state, KEPRO is the QIO for SC. The QIO doctors and other health experts review certain types of appeals and/or complaints made by Molina Dual Options patients. These include appeals and/or complaints about quality of care and appeals and/or complaints from Molina Dual Options patients who think the coverage for their hospital stay is ending too soon. You can refer to the Member Handbook for information on how to contact your state QIO.

(844) 455-8708 This call is free.
KEPRO team members are available 9:00 a.m. to 5:00 p.m. Monday
through Friday and from 11:00 a.m. to 3:00 p.m. on Saturdays,
Sundays, and holidays. You can also leave a message 24 hours a day,seven days a week.
Translation services are available for members and caregivers who do not speak English.

(855) 843-4776 This call is free.
This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.

KEPRO
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
http://www.keproqio.com/

Getting a QIO review of your hospital discharge

If you want to have your discharge reviewed, you must act quickly to contact the QIO. The Detailed Notice of Discharge & Molina Dual Options Appeal Rights, gives the name and telephone number of your QIO and tells you what you must do.

You must ask the QIO for a "fast review" of whether you are ready to leave the hospital. This "fast review" is also called a "fast appeal" because you are appealing the discharge date that has been set for you.
You must call the QIO before you leave the hospital and no later than your planned discharge date. This deadline is very important. If you meet this deadline, you are allowed to stay in the hospital past your discharge date without paying for it yourself, while you wait to get the decision from the QIO (see below).
If the QIO reviews your discharge, it will first look at your medical information. Then it will give an opinion about whether it is medically appropriate for you to be discharged on the date that has been set for you. By noon of the day after the reviewers tell us about your appeal, you will get a letter that gives your planned discharge date.

- If the QIO decides that your discharge date was medically appropriate, you will not be responsible for paying the hospital charges until noon of the calendar day after the QIO gives you its decision.
If the QIO agrees with you, then we will continue to cover your hospital stay for as long as medically necessary.

- What if you do not ask the QIO for a review by the deadline?
You still have another option: asking Molina Dual Options for a "fast appeal" of your discharge

- If you do not ask the QIO for a "fast review" ("fast appeal") of your discharge by the deadline, you can ask us for a "fast appeal" of your discharge. How to ask us for a fast appeal is covered briefly in the first part of this section and in more detail in the Member Handbook.

- If you ask us for a fast appeal of your discharge and you stay in the hospital past your discharge date, you run the risk of having to pay for the hospital care you receive past your discharge date. Whether you have to pay or not depends on the decision we make.

- If we decide, based on the fast appeal, that you need to stay in the hospital, we will continue to cover your hospital care for as long as medically necessary. If we decide that you should not have stayed in the hospital beyond your discharge date, then we will not cover any hospital care you received if you stayed in the hospital after the discharge date.
You may have to pay if you stay past your discharge date

- If you stay in the hospital after your discharge date and do not ask for immediate QIO review, you may be financially responsible for the cost of many of the services you receive. However, you can appeal any bills for hospital care you receive, by contacting Member Services.

When you are a patient in a SNF, Home Health Agency (HHA), or Comprehensive Outpatient Rehabilitation Facility (CORF), you have the right to get all the SNF, HHA or CORF care covered by Molina Dual Options that is necessary to diagnose and treat your illness or injury. The day we end your SNF, HHA or CORF coverage is based on when your stay is no longer medically necessary. This part explains what to do if you believe that your coverage is ending too soon.

Information you will receive during your SNF, HHA or CORF stay

If we decide to end our coverage for your SNF, HHA, or CORF services, you will get written notice either from us or your provider at least 2 calendar days before your coverage ends. You (or someone you authorize) will be asked to sign and date this document to show that you received the notice. Signing the notice does not mean that you agree that coverage should end - it only means that you received the notice.

How to get a review of your coverage by the Quality Improvement Organization

You have the right by law to ask for an appeal of our termination of your coverage. As will be explained in the notice you get from us or your provider, you can ask the Quality Improvement Organization (the "QIO") to do an independent review of whether our terminating your coverage is medically appropriate.

How soon you have to ask the QIO to review your coverage?

Call the Quality Improvement Organization before you leave the hospital and no later than your planned discharge date.

If you call before you leave, you are allowed to stay in the hospital after your planned discharge date without paying for it while you wait to get the decision on your appeal from the Quality Improvement Organization.

If you do not call to appeal, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you get after your planned discharge date.

If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to our plan instead.

We want to make sure you understand what you need to do and what the deadlines are, if you would like our help please call Molina Dual Options at (855) 735-5831, TTY: 711, 7 days a week, 8 a.m. to 8 p.m., local time. The call is free.

What will happen during the review?

If the QIO reviews your case, the QIO will ask for your opinion about why you believe the services should continue. You do not have to prepare anything in writing, but you may do so if you wish. The QIO will also look at your medical information, talk to your doctor, and review other information that we have given to the QIO. You and the QIO will each get a copy of our explanation about why your services should not continue.

After reviewing all the information, the QIO will give an opinion about whether it is medically appropriate for your coverage to be terminated on the date that has been set for you. The QIO will make this decision within one full day after it receives the information it needs to make a decision.

What happens if the QIO decides in your favor?

If the QIO agrees with you, then we will continue to cover your SNF, HHA or CORF services for as long as medically necessary.

What happens if the QIO denies your request?

If the QIO decides that our decision to terminate coverage was medically appropriate, you will be responsible for paying the SNF, HHA or CORF charges after the termination date on the advance notice you got from us or your provider. Neither Original Medicare nor Molina Dual Options will pay for these services. If you stop receiving services on or before the date given on the notice, you can avoid any financial liability.

What if you do not ask the QIO for a review in time?

You still have another option: asking Molina Dual Options for a "fast appeal" of your discharge.

If you do not ask the QIO for a "fast appeal" of your plan discharge date, you can ask us for a "fast appeal" of your discharge. How to ask us for a fast appeal is covered briefly in the first part of this section and in more detail in the Member Handbook.

If you ask us for a fast appeal of your termination and you continue getting services from the SNF, HHA, or CORF, you run the risk of having to pay for the care you receive past your termination date. Whether you have to pay or not depends on the decision we make.

If we decide, based on the fast appeal, that you need to continue to get your services covered, then we will continue to cover your care for as long as medically necessary.
If we decide that you should not have continued getting coverage for your care, then we will not cover any care you received if you stayed after the termination date. You may have to pay if you stay past your discharge date.

If you do not ask the QIO by noon after the day you are given written notice that we will be terminating coverage for your SNF, HHA or CORF services, and if you stay in the SNF, HHA or CORF after this date, you run the risk of having to pay for the SNF, HHA or CORF care you receive on and after this date. However, you can appeal any bills for SNF, HHA or CORF care you receive by contacting Member Services.