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What is a denial? A denial means Molina Healthcare is telling a provider and you that services will not be covered by your plan, or that bills will not be paid. If we deny your service or claim, you have the right to request why your services or bills were denied. You also have the right to appeal. An appeal is a request to review an action or denial made by Molina Healthcare of Utah.

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

How to file an appeal 

All appeals must be filed in 60 days from the date on the Notice of Adverse Benefit Determination. If you call, you may be asked to send more information in writing.

To file an appeal, you can:

• Call Member Services (888) 483-0760 (TTY/TDD: 711), Monday thru Friday from 9:00 a.m. to 5:00 p.m., local time. 

• Write a letter to us.

Mail the letter to: 

Molina Healthcare of Utah
ATTN: Appeals and Grievances
P.O. Box 182273
Chattanooga, TN 37422

We will send the member a letter acknowledging receipt of the appeal within five calendar days. All levels of Molina Healthcare’s appeal procedures will be completed in 30 calendar days.

Members may request a State Fair Hearing from the Utah Division of Health Care Financing within 120 days if the member disagrees with our decision to deny the appeal.

If you have any problems about the care you are getting, you must first request an appeal to Molina. Molina will provide a written notice and explain in clear terms the reason(s) for the denial of the appeal. If you are unhappy with Molina’s appeal decision, you have the right to request a State Fair Hearing from the State of Utah. A State Fair Hearing is an opportunity to give more information and facts, and to ask questions about the decision before an administrative law judge. The judge is not part of Molina in any way. This must be done within 120 days from the date of Molina Healthcare of Utah’s Notice of Appeal Resolution.

If a member is currently receiving a medical service that is going to be reduced or stopped, he/she may continue to receive the same medical service until the hearing if the hearing is requested within 10 days from the date the denial letter was postmarked or personally delivered to the member, or before the date of medical service is needed.

Submit your request by:

• Downloading and completing the Utah State Medicaid Form to Request a State Fair Hearing here. 


• Call Director’s Office/Hearings Unit at (801) 538-6576.

Members have the right to bring someone who knows about the case to attend the hearing with the member. Members may also seek legal counsel to represent them. For more information on obtaining legal aid, contact Utah Legal Services.

Adverse Benefit Determination

An Adverse Benefit Determination is when we:

• Deny payment for care or approve payment for less care than you wanted.

• Lower the number of services you can get or end payment for a service that was approved.

• Deny payment for a covered service.

• Deny payment for a service that you may be responsible to pay.

• Did not decide on an appeal or grievance in a timely manner.

• Did not provide you with a doctor’s appointment in a timely manner. Timely manner means 30 days for a routine doctor visit and two days for an urgent care visit.

• Deny a member’s request to dispute a financial liability.

You have a right to receive a Notice of Adverse Benefit Determination if one of the above occurs. If you did not receive one, contact Member Services and we will send you a notice.

Appeal

An appeal is when you, your authorized representative, or your provider contacts us to review an Adverse Benefit Determination to see if the right decision was made to deny your request for service.

Grievance

A grievance is a complaint about the way your health care services were handled by your provider or Molina.

State Fair Hearing

A State Fair Hearing is a hearing you, your authorized representative, or your provider can request with the State Medicaid Hearings Unit if you are unhappy with our decision about your appeal.