Complaints and Appeals

As a Molina Healthcare member, if you have a problem with your medical care or our services, you have a right to file a complaint (grievance) or appeal. Some examples are:  

• The care you get from your provider.
• The time it takes to get an appointment or be seen by a provider.
• The providers you can choose for care.
   

An appeal can be filed when you do not agree with Molina Healthcare’s decision to: 
 

• Stop, change, suspend, reduce or deny a service.
• Deny payment for services provided.
   

What if I Have a Complaint?

If you have a problem with any Molina Healthcare services, we want to help fix it. You can call any of the following toll-free for help:

Call Molina Healthcare toll-free at (833) 657-1981, Monday to Friday, 8:00 a.m. - 6:00 p.m TTY users can dial 711.

You may also send us your problem or complaint in writing by mail or by registering to My Molina at https://member.molinahealthcare.com/Member/Login. Our address is:
Molina Healthcare of Idaho
PO Box 182273
Chattanooga, TN 37422

Call the Idaho Department of Insurance Commissioner’s Consumer Affairs Section at (208) 334-4319 or (800) 721-3272 or visit https://doi.idaho.gov/consumer/Complaint

Molina Healthcare recognizes the fact that Members may not always be satisfied with the care and services provided by our contracted doctors, hospitals and other providers. We want to know about Your problems and complaints. You may file a grievance (also called a complaint) in person, in writing, or by telephone as described above.
 

We will send You a letter acknowledging receipt of Your grievance within three (3) calendar days and will then issue a formal response within thirty (30) calendar days of the date of Your initial contact with us. All levels of grievances will be resolved within thirty (30) calendar days.
 

A Member Appeal may be requested by the member or his/her designee via telephone, fax, or mail within one-hundred eighty (180) calendar days after the member’s receipt of the Notice of Action (NOA).

We will send You a letter acknowledging receipt of Your appeal within three (3) calendar days. All levels of Molina Healthcare’s grievances and appeal procedures will be completed within fourteen (14) calendar days.
 

You must file Your grievance within one hundred eighty (180) calendar days from the day the incident or action occurred which caused You to be unhappy.
 

Expedited Review

If your grievance involves an imminent and serious threat to your health, Molina Healthcare will quickly review Your grievance. Examples of imminent and serious threats include, but are not limited to, severe pain, potential loss of life, limb, or major bodily function. You will be immediately informed of your right to contact the Department of Managed Health Care. Molina Healthcare will issue a formal response no later than three (3) calendar days after your initial contact with us. You may also contact the Department of Managed Health Care immediately and are not required to participate in Molina Healthcare’s grievance process.
 

Department of Managed Health Care Assistance

The Idaho Department of Insurance Commissioner’s Consumer Affairs Section is responsible for regulating health care services plans. If You have a grievance against Your health plan, You should first telephone Your health plan toll-free at (888) 858-2150, and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to You. If You need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by Your health plan, or a grievance that has remained unresolved for more than thirty (30) days, You may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If You are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll free telephone number (201) 334-4319 and a toll-free line (800) 721-3270 for the hearing and speech impaired. The department’s Internet website https://doi.idaho.gov/consumer/Complaint has complaint forms, IMR applications forms and instructions online.
 

External Review by an Independent Review Organization

Within one hundred and eighty (180) days after the Member has received Molina’s Final Internal Adverse Benefit Determination, or if Molina has not responded to a request for an Internal Review or Appeal within the time periods noted above, the Member may request an External Review or Appeal from an Independent Review Organization (IRO). Molina may require the Member to exhaust Molina’s review process prior to requesting an external review. If Molina does waive this requirement, and Molina then reverses the final Adverse Determination, Molina will immediately notify the member and the IRO. Requests for External Review or Appeals must be in writing and sent to Molina Customer Support at the mailing address or electronic mail address.

Upon receipt of a valid request for an External Review or Appeal, Molina will arrange for the review from an IRO, selected on a rotating basis, at no cost to the Member, and will provide the Member with the IRO contact information within 24 hours of selecting the IRO. The IRO is unbiased and not controlled by Molina. Molina will provide the IRO with the appeal documentation, but the Member may also provide them with information.

The IRO process is optional and the Member pays no application or processing fees of any kind. The Member has the right to give information in support of their request and has 5 business days from the request for an External Review or Appeal to submit any supporting written information to the IRO. If the member is receiving services that are the subject of the Appeal, those services will be continued until the matter is resolved by the IRO. If Molina’s Adverse Benefit Determination is upheld by the IRO, the Member may be responsible for paying for any services that have been continued during the External Review or Appeal.

The dispute will be submitted to the IRO’s medical reviewers who will make an independent determination of whether or not the care is Medically Necessary or appropriate and the application of this Agreement’s coverage provisions to the Member’s health care services. All documents submitted to the IRO will also be made available to the Member. This includes all relevant clinical review criteria, all relevant evidence, Provider’s recommendations, and a copy of this Agreement. The Member will get a copy of the IRO’s Final External Review Decision. If the IRO determines the service is Medically Necessary or appropriate for coverage under the Agreement, Molina will provide the health care service.

If the Member’s case involves Experimental or Investigational treatment, the IRO will ensure that adequate clinical and scientific experience and protocols are considered.
For non-urgent cases, the IRO must provide its determination within the earlier of fifteen (15) days after the IRO receives the necessary information or twenty (20) days of receipt of their request.
Members may request an expedited External Review or Appeal if one of the following conditions apply:

• The Member receives a Final Adverse Benefit Determination concerning an admission, availability of care, continued stay, or health care service for which the Member received emergency services and has not been discharged from the facility.
• The Member received a Final Adverse Benefit Determination involving a medical condition for which the standard external review time would seriously jeopardize the Member’s life or health or jeopardize the Member’s ability to regain maximum function.
• The Member’s request for a concurrent expedited review is granted. If the External Review or Appeal is expedited, the IRO must notify the Member within 72 hours of its Final External Review Decision. If the notice is not in writing, the IRO must provide the Member with written confirmation of its Final External Review Decision within 48 hours after the date of the decision.