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:
- Please call us toll-free Monday through Friday, from 8:00 a.m. to 6:00 p.m. EST. at 1 (888) 560-4087. If you are hearing impaired or have a speech disability, you may call our toll-free TTY number at 1 (800) 735-2989, or you may use a relay service by dialing 711.
- You may also send us Your problem or complaint in writing by mail or filing online at our website. Our address is:
Molina Healthcare
Grievance and Appeals Unit
880 West Long Lake Road
Troy, MI 48098
www.molinahealthcare.com
Two Types of Grievances
There are two types of grievances. An administrative grievance is when You have a complaint or disagree with a Molina Healthcare decision relating to the availability, delivery or quality of health care services. An Adverse Benefit Determination grievance is one where You disagree with an Adverse Benefit Determination made by Molina Healthcare. The process for addressing a grievance depends on the type of grievance. The Administrative Grievance Process is described immediately below. The Adverse Benefit Determination Grievance and Appeal Process is described in the Appeals section following the Administrative Grievance Process section.
For purposes of the Administrative Grievance Process, Adverse Benefit Determination Grievance and Appeal Process, External Review Process sections, the term You shall include Your authorized representative.
ADMINISTRATIVE GRIEVANCE PROCESS
You may submit Your administrative grievance to Molina Healthcare by:
- Calling us toll-free Monday through Friday, from 8:00 a.m. to 6:00 p.m. EST at 1 (888) 560-4087. If you are hearing impaired or have a speech disability, you may call our toll-free TTY number at 1 (800) 735-2989, or you may use a relay service by dialing 711.
- Sending us your administrative grievance in writing by mail to our address:
Molina Healthcare
Grievance and Appeals Unit
880 West Long Lake Road, Troy, MI 48098
Troy, MI 48098 www.molinahealthcare.com
We will send you a letter acknowledging receipt of Your grievance within five (5) calendar days and will then issue a formal response within thirty-five (35) calendar days of the date of Your initial contact with us.
If you are not satisfied with our response to your administrative grievance you may be able to file an appeal with Molina Healthcare if it is received and can be processed within thirty-five (35) calendar days of the initial receipt of the administrative grievance. We will send you a letter acknowledging receipt of your appeal within five (5) calendar days. All levels of Molina Healthcare’s grievances and appeal procedures will be completed within thirty-five (35) calendar days. However, this period may be extended by up to 10 business days if Molina Healthcare has requested and not received information from your provider and you agree.
You must file your grievance within 180 days from the day the incident or action occurred which caused you to be unhappy.
If your administrative grievance involves an imminent and serious threat to your health, Molina Healthcare will quickly review your administrative grievance. Examples of imminent and serious threats include, but are not limited to, severe pain, potential loss of life, limb, or major bodily function. Molina Healthcare will issue a formal response no later than seventy-two (72) hours. Within ten (10) days after receipt of formal response, You may request a review of your grievance from the Department of Insurance and Financial Services (DIFS).
APPEALS
Definitions
The capitalized terms used in this appeals section have the following definitions:
“Adverse Benefit Determination”: means
- A denial of a request for service or a failure to provide or make payment (in whole or in part) for a benefit;
- Any reduction or termination of a benefit, or any other coverage determination that an admission, availability of care, continued stay, or other health care service does not meet Molina’s requirements for Medical Necessity, appropriateness, health care setting, or level of care or effectiveness; or
- Based in whole or in part on medical judgment, includes the failure to cover services because they are determined to be experimental, investigational, cosmetic, not Medically Necessary or inappropriate.
- A decision by Molina to deny coverage based upon an initial eligibility determination.
An Adverse Benefit Determination is also a rescission of coverage as well as any other cancellation or discontinuance of coverage that has a retroactive effect, except when such cancellation/discontinuance is due to a failure to timely pay required Premiums or contributions toward cost of coverage.
The denial of payment for services or charges (in whole or in part) pursuant to Molina’s contracts with network providers, where You are not liable for such services or charges, are not Adverse Benefit Determinations.
“Authorized Representative”: means an individual authorized in writing by You or state law to act on the Your behalf in requesting a health care service, obtaining claim payment, or during the internal appeal process. A health care provider may act on behalf of You without Your express consent when it involves an Urgent Care Service.
Authorized Representative Form
“Final Adverse Benefit Determination” means an Adverse Benefit Determination that is upheld after the internal appeal process. If the time period allowed for the internal appeal elapses without a determination by Molina Healthcare, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.
“Post-Service Claim”: means an Adverse Benefit Determination has been rendered for a service that has already been provided.
“Pre-Service Claim”: means an Adverse Benefit Determination was rendered and the requested service has not been provided.
“Urgent Care Services Claim”: means an Adverse Benefit Determination was rendered and the requested service has not been provided, where the application of non-urgent care appeal time frames could seriously jeopardize:
- Your life or health or the Your unborn child; or
- In the opinion of the treating physician, would subject You to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
Internal Appeal
You or Your Authorized Representative, or a treating Provider or facility may submit an appeal of an Adverse Benefit Determination. Molina will provide You with the forms necessary to initiate an appeal.
You may request these forms by contacting Molina Healthcare at the telephone number listed on the Member ID card. While You are not required to use Molina Healthcare’s pre-printed form, Molina Healthcare strongly encourages that an appeal be submitted on such a form to facilitate logging, identification, processing, and tracking of the appeal through the review process.
You may also request the clinical review criteria used to determine medical necessity in your particular situation by contacting the Grievance and Appeals Coordinator at 1-888-560-4087. If you are hearing impaired or have a speech disability, you may call our toll-free TTY number at 1 (800) 735-2989, or you may use a relay service by dialing 711.
If you need assistance in preparing the appeal, or in submitting an appeal verbally, You may contact Molina Healthcare for such assistance at:
Molina Healthcare of Michigan, Inc.
Attn: Grievance and Appeals Coordinator
880 West Long Lake Road, Troy, MI, 48098
Troy, MI 48098
Phone: 1 (888) 560-4087
TTY: 1 (800) 735-2989 or 711
If appealing an Adverse Benefit Determination, You (or Your Authorized Representatives) must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination.
Within five (5) business days of receiving an appeal, Molina will send You (or Your Authorized Representative) a letter acknowledging receipt of the appeal.
The appeal will be reviewed by personnel who were not involved in the making of the Adverse Benefit Determination and will include input from a health care professional in the same or similar specialty as typically manages the type of medical service under review.
| TIMEFRAME FOR RESPONDING TO APPEAL |
| REQUEST TYPES |
TIMEFRAME FOR DECISION |
| URGENT CARE SERVICE |
WITHIN 72 HOURS. |
| PRE-SERVICE AUTHORIZATION |
WITHIN 30 CALENDAR DAYS. |
CONCURRENT SERVICE (A
REQUEST TO EXTEND OR
A DECISION TO REDUCE A
PREVIOUSLY APPROVED
COURSE OF TREATMENT) |
WITHIN 72-HOURS FOR URGENT CARE SERVICES AND 30 CALENDAR DAYS FOR OTHER SERVICES. |
| POST-SERVICE AUTHORIZATION |
WITHIN 60 CALENDAR DAYS. |
Exhaustion of Process
The foregoing procedures and process are mandatory and must be exhausted prior to establishing litigation or arbitration or any administrative proceeding regarding matters within the scope of this Complaints and Appeals section.
General Rules and Information
General rules regarding Molina Healthcare’s Complaint and Appeal Process include the following:
- You must cooperate fully with Molina in Our effort to promptly review and resolve a complaint or appeal. In the event You do not fully cooperate with Molina Healthcare, You will be deemed to have waived Your right to have the Complaint or Appeal processed within the time frames set forth above.
- Molina Healthcare will offer to meet with You by telephone. Appropriate arrangement will be made to allow telephone conferencing to be held at Our administrative offices. Molina will make these telephone arrangements with no additional charge to You.
- During the review process, the services in question will be reviewed without regard to the decision reached in the initial determination.
- Molina Healthcare will provide You with new or additional informational evidence that it considers, relies upon, or generates in connection with an appeal that was not available when the initial Adverse Benefit Determination was made. A “full and fair” review process requires Molina Healthcare to send any new medical information to review directly so You have an opportunity to review the claim file.
Telephone Numbers and Addresses
You may contact a Molina Healthcare Grievance and Appeals Coordinator at the number listed on the acknowledgement letter or notice of Adverse Benefit Determination or Final Adverse Benefit Determination. Below is a list of phone numbers and addresses for grievances and appeals.
Molina Healthcare of Michigan, Inc.
Member Services Department
880 West Long Lake Road
Troy, MI 48098
Phone: 1 (888) 560-4087
TTY: 1 (800) 735-2989 or 711
www.molinahealthcare.com
EXTERNAL REVIEW PROCESS
You may request an external review of an Adverse Benefit Determination from the Michigan Department of Insurance and Financial Services (DIFS) only after exhausting the Molina Healthcare’s internal review process described above unless: (1) Molina Healthcare agrees to waive our internal review process; (2) Molina Healthcare has not complied with the requirements of our internal review process; or (3) You request an expedited external review at the same time You request an expedited internal review.
How to File an External Review Request
You must file a request with the Michigan Department of Insurance and Financial Services for an external review (sometimes also referred to as “independent review”) of an Adverse Benefit Determination no later than 180 days after You receive the Final Adverse Benefit Determination notice from Molina. You must use the Health Care Request for External Review form to file the request which is available from either Molina Healthcare Member Services Department at 1 (888) 560-4087 or
Department of Insurance and Financial Services
Health Plans Division - Appeals Section
P.O. Box 30220
Lansing. Michigan 48909-7720
1 (877) 999-6442
www.michigan.gov/difs
The external review request must contain an authorization for the necessary parties to obtain medical records for purposes of making a decision on the external review request.
The external review decision is binding on Molina Healthcare and the Member except to the extent that other remedies are available under federal and state laws.
Standard External Review
Within five (5) business days of receiving the Health Care Request for External Review form, the Michigan Insurance Commissioner will complete a preliminary review of the request to determine whether: (a) the individual was a Member at the time of rescission or the health care service was requested or provided; (b) whether the health care service that is the subject of the Adverse Benefit Determination is reasonably a covered service; (c) the Member has exhausted Molina Healthcare’s external review process described above; (d) the Member has provided all the information and forms required for the external review; and (e) the Adverse Benefit Determination involves issues of Medical Necessity or clinical review.
If the request is not complete, the Michigan Insurance Commissioner will inform You of what information or materials are needed to make the request complete. If the request is not eligible for external review, the Michigan Insurance Commissioner will inform You in writing of the reasons why the request is not eligible for external review. If a request is eligible for external review, the Michigan Insurance Commissioner will: (1) notify Molina Healthcare of acceptance of the request for external review of an Adverse Benefit Determination; and (2) notify You that the request has been accepted and that You may submit additional information within 7 business days of receipt of the Michigan Insurance Commissioner’s notice.
If the Michigan Insurance Commissioner determines that the Adverse Benefit Determination involves an issue of Medical Necessity or clinical review criteria, the Michigan Insurance Commissioner will assign the request for external review to an approved indepemndent review organization. If the Adverse Benefit Determination does not involve issues of Medical Necessity or clinical review criteria, the Michigan Insurance Commissioner will conduct the review.
The independent review organization will provide its written recommendation to uphold or reverse the Adverse Benefit Determination to the Michigan Insurance Commissioner not later than 14 days after being assigned the request to review the Adverse Benefit Determination. The Michigan Insurance Commissioner will notify You and Molina Healthcare of his or her decision to uphold or reverse the Adverse Benefit Decision within seven (7) business days after receiving the external review organizations recommendation. If the Michigan Insurance Commissioner conducts the review of the Adverse Benefit Determination because it does not involve issues of Medical Necessity or clinical review criteria, the Michigan Insurance Commissioner will notify You and Molina Healthcare of his or her decision within fourteen (14) business days after he or she makes the decision to conduct the review himself or herself. If the Adverse Benefit Determination is reversed, Molina Healthcare will immediately approve the coverage that was the subject of the Adverse Benefit Determination and process any benefit that is due.
Expedited External Review Requests
You may request an expedited external review when: (1) the Adverse Benefit Determination involves a medical condition which would seriously jeopardize the life and health of the Member or jeopardize the Member’s ability to regain maximum function; (2) You have filed a request for expedited internal review of the Adverse Benefit Determination with Molina Healthcare as described above; and (3) You make the request for an expedited external review within ten (10) days of receiving the Adverse Benefit Determination.
Upon receipt of the Health Care Request for External Review form, the Michigan Insurance Commissioner will immediately send a copy of the request to Molina Healthcare. If the Michigan Insurance Commissioner determines that the request to review an Adverse Benefit Determination involves an issue of Medical Necessity or clinical review criteria, he or she will assign the request for an expedited review to an independent review organization. The independent review organization will decided immediately whether You will be required to first complete the expedited internal review process. If the independent review organization determines that You must complete the expedited internal review process it will immediately notify You. The independent review organization will provide its recommendation of whether to uphold or reverse the Advance Benefit Determination as soon as expeditiously as the Member’s medical condition or circumstances require, but in no event more than thirt-six (36) hours after the date the Michigan Insurance Commissioner received the request for an expedited external review. As expeditiously as the Member’s medical condition or circumstances require, but in no event more than twenty-four (24) hours after receiving the independent review organization’s recommendation, the Michigan Insurance Commissioner will notify You and Molina Healthcare of the decision to uphold or reverse the Adverse Benefit Determination. If the notice is not in writing, the Michigan Insurance Commissioner will provide written confirmation of the decision to You and Molina Health care within two (2) days after providing the original notice of his or her decision.
Find helpful resources, plan materials, payment information and more.
×
