How to File Grievances and Appeals
We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. Please call Member Services
See Chapter 9 of the EOC* for detailed information about how to make an appeal that involves a request for Part D drug benefits.
This section gives the rules for making complaints in different types of situations. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your medical care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Molina Medicare or penalized in any way if you make a complaint.
What are appeals and grievances?
You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "grievances" are the two different types of complaints you can make.
- An "appeal" is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Molina Medicare or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Molina Medicare or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal.
- A "grievance" is the type of complaint you make if you have any other type of problem with Molina Medicare or one of our plan providers. For example, you would file a grievance if you have a problem with things such as the quality 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.
To obtain information on the process or status, or on the number of grievances, appeals, and exceptions filed with Molina Medicare, please call Member Services.
- This section tells how to make complaints in different situations
The rest of this section has separate parts that tell you how to make a complaint in each of the following situations:
1. Complaints about what we will cover for you or what we will pay for. If Molina Medicare or your doctor or another plan provider has refused to give you a service you think is covered, you can make a complaint called 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. Complaints about your Part D prescription drug benefits that we will cover or pay for. If Molina Medicare 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 Chapter 9 of the EOC* so that you clearly understand the difference.
3. Complaints 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. Your state QIO is a group of health professionals that are paid to handle this type of appeal from Medicare 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 act very quickly to make this type of appeal, and it will be decided quickly.
4. Complaints 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 Health Services Advisory Group, 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 Medicare 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 grievance to complain about 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 grievance with Molina Medicare. But for many problems related to quality of care you get from plan providers, you can also complain to the QIO in your state.
- Part 1. Complaints (appeals) to Molina Medicare to change a decision about what services we will cover or what we will pay for
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 Medicare.
- 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 Medicare.
- 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 Medicare while you were a member, but we have refused to pay for this care.
Six possible steps for requesting care or payment from Molina Medicare:
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 Medicare program or the federal court system.
The six possible steps are summarized below (they are covered in more detail Chapter 9 of the EOC* ).
Step 1: The initial decision by Molina Medicare
The starting point is when we make an "initial decision" (also called an "organization determination") about your medical care or about paying for care you have already received. When we make an "initial decision," we are giving our interpretation of how the benefits and services that are covered for members of Molina Medicare apply to your specific situation. As explained in Chapter 9 of the EOC* you can ask for a "fast initial decision" if you have a request for medical care that needs to be decided more quickly than the standard time frame.
Step 2: Appeal to Molina Medicare
You may ask us to review our initial determination, even if only part of our decision is not what you requested. When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look.
Step 3: Review of your request by an Independent Review Organization
If we turn down part or all of your request in Step 2, we are required to send your request to an independent review organization that has a contract with the federal government and is not part of Molina Medicare. This organization will review your request and make a decision about whether we must give you the care or payment you want.
Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the independent review organization that reviews your case in Step 3, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your contested benefit must be at least $180 to be considered in Step 4.
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. This Council is part of the federal department that runs the Medicare 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 $1840 to go to a Federal Court.
For a more detailed explanation of all six steps outlined above, see Chapter 9 of the EOC*.
- Part 2. Complaints (appeals) to Molina Medicare to change a decision about what Part D drugs we will cover or pay for
This part of Chapter 9 of the EOC* 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 Medicare.
- If you have received a Part D prescription drug you believe may be covered by Molina Medicare 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 disagree with the amount that we require you to pay for a Part D prescription drug that your doctor has prescribed for you.
- 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 Medicare
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 Medicare program or the federal court system.
The six possible steps are summarized below (they are covered in more detail in Chapter 9 of the EOC*).
Step 1: The initial decision by Molina Medicare
The starting point is when we make an "initial decision" (also called a "coverage determination") about your Part D prescription drug or about paying for Part D drug that you have already received. When we make an "initial decision," we are giving our interpretation of how the benefits that are covered for members of Molina Medicare apply to your specific situation. As explained in Chapter 9 of the EOC*, you can ask for a "fast initial 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 Medicare
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 Chapter 9 of the EOC*, 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 by an Independent Review Organization
If we turn down your request in Step 2, you may ask an independent review organization to review our decision. The independent review organization has a contract with the federal government and is not part of Molina Medicare. The independent review organization will review your request and make a decision about whether we must give you the benefit or payment you want.
Step 4: Review by an Administrative Law Judge
If you are unhappy with the decision made by the independent review organization that reviews your case in Step 3, you may ask for an Administrative Law Judge to consider your case and make a decision. The Administrative Law Judge works for the federal government. The dollar value of your contested benefit must be at least $180 to be considered in Step 4.
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. The MAC is part of the federal department that runs the Medicare 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 $1840 to go to a Federal Court
For a more detailed explanation of all six steps outlined above, see Chapter 9 of the EOC*.
- Part 3. Complaints (appeals) if you think you are being discharged from the hospital too soon
When you are hospitalized, you have the right to get all the hospital care covered by Molina Medicare 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 part of Chapter 9 of the EOC* 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 the Important Message from Medicare. 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 Notice of Discharge & Medicare 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 Notice of Discharge & Medicare 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 Medicare patients. They are not part of our health plan or your hospital. There is one QIO in each state. QIOs have different names, depending on which state they are in. The QIO doctors and other health experts review certain types of complaints made by Medicare patients. These include complaints about quality of care and complaints from Medicare patients who think the coverage for their hospital stay is ending too soon. You can refer to Chapter 9 of the EOC* for information on how to contact your state QIO.
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 Notice of Discharge & Medicare 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 be sure that you have made your request to the QIO no later than noon on the first working day after you are given written notice that you are being discharged from the hospital. 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. The QIO will make this decision within one full working day after it has received your request and all of the medical information it needs to make a decision.
- 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 Medicare 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 Chapter 9 of the EOC*.
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, using Step 1 of the appeals process described in Chapter 9 of the EOC*.
- Part 4. Complaints (appeals) if you think your coverage for SNF, home health, or comprehensive outpatient rehabilitation facility services are ending too soon.
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 Medicare 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?
If you want to have the termination of your coverage appealed, you must act quickly to contact the QIO. The written notice you got from us or your provider gives the name and telephone number of your QIO and tells you what you must do.
- If you get the notice 2 days before your coverage ends, you must be sure to make your request no later than noon of the day after you get the notice.
- If you get the notice and you have more than 2 days before your coverage ends, then you must make your request no later than noon of the day before the date that your Medicare coverage ends.
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 Medicare 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 Medicare for a "fast appeal" of your discharge.
If you do not ask the QIO for a "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 Chapter 9 of the EOC*.
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 using Step 1 of the appeals process described in Chapter 9 of the EOC*.
- Part 5. Complaints (grievances) about any other type of problem you have with Molina Medicare or one of our plan providers
Chapter 9 of the EOC* , How to File a Grievance, explains how to make complaints about any other type of problem that has not already been discussed above. (The problems that have already been discussed are problems related to coverage or payment for care or Part D benefits, problems about being discharged from the hospital too soon, and problems about coverage for SNF, HHA, or CORF services ending to soon.)
What is included in "all other types of problems"?
Here are some examples of problems that are included in this category of "all other types of problems":
- Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
- If you feel that you are being encouraged to leave (disenroll from) Molina Medicare.
- Problems with the Member Service you receive.
- Problems with how long you have to spend waiting on the phone, in the waiting room, or in the exam room.
- Problems with getting appointments when you need them, or having to wait a long time for an appointment.
- Disrespectful or rude behavior by doctors, nurses, receptionists, or other staff.
- Cleanliness or condition of doctor's offices, clinics, or hospitals.
If you have one of these types of problems and want to make a complaint, it is called "filing a grievance." In addition, you have the right to ask for a "fast grievance" if you disagree with our decision to not give you a "fast appeal" or if we take an extension on our initial decision or appeal. See below for more detail.
Filing a grievance with Molina Medicare
If you have a complaint, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Member Grievance Process.
You must file your grievance within 60 days of the event that gives rise to the grievance. You may file a grievance either orally or in writing, by one of the methods below.
Please call Member Services
TTY 711
This number requires special telephone equipment. Calls to this number are free.FAX (866) 771-0117
WRITE
Molina Healthcare
ATTN: Grievance and Appeals Department
PO Box 22816
Long Beach, CA 90801-9977We will respond to all written grievances in writing. We will respond to oral grievances orally, unless you specifically request a written response. We will respond to all quality of care grievances in writing, regardless of how the grievance was filed.
Expedited Grievance Procedure:
You (or your representative, with appropriate authorization) are entitled to an expedited grievance whenever Molina Medicare takes an extension relating to an organization determination reconsideration, or when we refuse to expedite a request for an organization determination or reconsideration. Molina Medicare will respond to these grievances with 24 hours after receipt. Our expedited grievance determination will address only your dissatisfaction with our decision to take an extension or deny your request to expedite a determination or appeal. The grievance determination will not address the underlying issue (request for services or payment, etc.) that is the subject of the organization determination or reconsideration. For after hours, weekend, or holiday delivery please contact our Nurse Advice Line which is available 24 hours a day 7 days a week at (888) 275-8750 and (866) 735-2929 for TTY users.
Standard Grievance Procedure:
For all other grievances, we will make a decision and notify you of our decision as your case requires based on your health status, but not later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
For quality of care problems, you may also complain to the QIO
If you are concerned about the quality of care you received, including care during a hospital stay, you can also contact an independent organization called the QIO. See Chapter 9 of the EOC* for more information about the QIO.
Chapter 9 of the EOC* : Links in this section go to the Evidence of Coverage
Molina Medicare is an organization with a Medicare contract. This contract is renewed annually, and coverage beyond the end of the current benefit year is not guaranteed.