Members

You have the right to appeal a denial

appeal

What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be given or bills will not be paid. If we deny your service or claim, you can ask why your services or bills were denied. You ask for an appeal.

If your service or claim is denied, you will get a letter from Molina Healthcare telling you about this decision. It will tell you about your right to appeal. You can also read about these rights in your Member Handbook.

CHIP members have 60 days to request an appeal from the date the Notice of Action letter is mailed. 

How to appeal a Denial

Member Services staff can also help you file an appeal. You can call Member Services at:

  • (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-6826
    • TTY English (800) 735-2989 or dial 711
    • Texas Relay Spanish (800) 662-4954

Or

    ·         Fill out the Complaint / Appeal form and mail it to:
    Molina Healthcare of Texas
    Appeals and Grievances
    P.O. Box 182273
    Chattanooga, TN 37422

  • Email: TxMemberInquiryResearchandResolution@MolinaHealthcare.com


    • ·         Be sure to include the following:

      ·         Member's first and last name

      ·         Molina Healthcare ID number. It is on the front of the Member ID Card

      ·         Member's address and telephone number

      ·         Explain the problem

If you would like to check the status of your appeal, please call Member Services at (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-3826.

You can learn more about appealing a CHIP denial in your member handbook.

External Medical Review

If you are not happy with the result of your appeal for a disputed healthcare service, you can ask for an external medical review from an Independent Review Organization (IRO). The External Medical Review process is managed by MAXIMUS Federal Services for CHIP members. This means, providers outside Molina Healthcare, review all the facts in your case and make a decision. We will accept that finding.

CHIP members must request an appeal and go through the entire appeal process with Molina before requesting an external medical review. If outcome of the appeal is NOT in member's favor, the member can request an external medical review.

How to ask for an External Medical Review:
If you would like to request an external medical review after completing Molina’s appeal process, you must fill out the HHS Federal External Review Request Form that is sent with appeal resolution letter. Include your adverse benefit determination letter and/or appeal resolution letter from Molina when mailing or faxing your request to MAXIMUS. This form will be sent to you with your appeal decision letter, but if you need another copy, Molina can provide a copy to you.

Send your request for External Medical Review directly to MAXIMUS at:

MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

Fax number: 1-888-866-6190

If you need help submitting your External Medical Review request, you can:

  • Call Member Services at (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-3826
  •  Mail your written request to:
    Molina Healthcare of Texas
    Appeals and Grievances
    P.O. Box 182273
    Chattanooga, TN 37422

Or

If you have questions or would like to check the status of your external medical review, please call Member Services at (866) 449-6849 or CHIP Rural Services Area (RSA) (877) 319-3826.

You can learn more about external medical reviews in your member handbook.