Complaints and Appeals

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Definitions for This Section

“Authorized Representative” means an individual who is authorized to act on Your behalf with respect to a Grievance, either by law or in accordance with Molina’s processes

“Grievance” means any dissatisfaction with Molina that is expressed, in writing, to Molina by You, or Your Authorized Representative:

 “Expedited Review” means a review of a Grievance involving an Adverse Determination where the standard resolution process may include any of the following:

  • Serious jeopardy to Your life or health (or the life or health of Your unborn child) or Your ability to regain maximum function; 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 Grievance; or 
 
  • Is determined to be an expedited Grievance by the treating physician 
 

“Standard Review” means a review that does not require a decision to be made on an urgent basis and does not involve any of the conditions listed above in “Expedited Review”.

What if I Have a Complaint, also known as a Grievance?

If You have a problem with any Molina Healthcare services, We want to help fix it

Member Grievance/Appeal Request Form

Filing a Grievance

You or Your Authorized Representative may file aGrievance by phone by calling Molina toll-free at (866) 472-9484, Mondaythrough Friday, 8:00 a.m. to 5:00 p.m. CT.  If You are deaf or hard of  hearing, You may contact Us by dialing 7-1-1 for the TelecommunicationsRelay Service.You can also submit Your Grievance in writing, along with any supporting materials by mail or fax to:

By mail:

Attn: Grievance Coordinator

188 E. Capitol St.

Jackson, MS 39201

By fax:

Fax: 1 (844) 808-2407


You can also submit Your Grievance in writing to the Mississippi Insurance Department

MISSISSIPPI INSURANCE DEPARTMENT

P.O. BOX 79

JACKSON, MISSISSIPPI 39205-0079


You may also call 1 (800) 562-2957or 7-1-1 (TTY) and ask for 1 (601) 359-3569 to request acomplaint form.  The Complaint Form is also available at http://www.mid.ms.gov/consumers/online-complaint.aspx You may e-mail them at: consumer@mis.ms.gov.

You can find additional information regardingGrievances on Our website at: MolinaMarketplace.com     

Molina will acknowledge receipt of the Grievancein writing within five business days of receiving it.  If Your AuthorizedRepresentative filed the Grievance on Your behalf, We will also provide anotice that health care information or medical records may be disclosed only ifpermitted by law.  We will also include an informed consent form.  

Molina will notify You and Your AuthorizedRepresentative (if applicable) in writing of the resolution of Your Grievancewithin 30 calendar days from the time we received Your written Grievance..            

Requesting Internal Review of a Grievance Involving an Adverse Determination

You or Your Authorized Representative may file a request for an internal review of an Adverse Determination within 180 days from receipt of the Adverse Determination. Please be sure to include any documents or information you would like Us to consider when We review your appeal. Molina will respond You in writing.

For a Standard Review, Our response will be provided to You within 30 calendar days of receipt of Your request. The time period may be extended for an additional 14 calendar days, if Molina provides You or Your Authorized Representative, with written notification, within the first 30 calendar days, of the date when Our resolution will be provided to You and, the reason additional time is needed.

For an Expedited Review, Our response will be provided to You within 72 hours of receipt of the request      

If You are not happy with Our response, You, or Your Authorized Representative may request an External Review of a Grievance involving an Adverse Determination from the Mississippi Insurance Commissioner, as outlined below.

Requesting Internal Review of a Grievance Involving an Adverse Determination

If You are not happy with Our response to Your request for review of a Grievance involving an Adverse Determination based on Medical Necessity, appropriateness of care, health care setting, level of care, or effectiveness of care, You or Your Authorized Representative may make a request for an External review to the Mississippi Insurance Department at the phone number, address or website shown below. Except for Expedited Review requests, You must exhaust Molina’s internal review process before making a request for an external review. When filing a request for an external review, You will be required to authorize the release of any medical records that may be required to be reviewed for the purpose of reaching a decision on the external review. A decision will be rendered by an independent review organization within 45 days of receiving your request. If Your  request qualifies for an Expedited Review of the Adverse Determination, a determination will be rendered on an external review as expeditiously as possible, but in no event more than 72 hours after receipt of an expedited review request that meets all applicable requirement. .

If the request is for a review of a Grievance based on an Adverse Determination that the service or treatment is experimental or investigational, You may also be entitled to file a request for external review of our denial with the Mississippi Insurance Department. An independent review organization will review your request and provide notice to you of its decision. Any such external review must be initiated within 4 months of the receipt of notice of an Adverse Determination. Requests for external review must be submitted through the Mississippi Insurance Department

Submitting a Grievance to the Office of the Commissioner of Insurance

You may resolve Your problem by taking the steps outlined above.  You may alsofile a complaint with the MISSISSIPPI INSURANCE DEPARTMENT.  The MISSISSIPPIINSURANCE DEPARTMENT is a state agency that enforces Mississippi'sinsurance laws.  You may contact the MISSISSIPPI INSURANCE DEPARTMENT bywriting to:

 MISSISSIPPI INSURANCE DEPARTMENTP. O. Box 79Jackson, MS 39205-0079

You mayalso call the MISSISSIPPI INSURANCE DEPARTMENT Complaints Department at 1(800) 562-2957 or 7-1-1 (TTY) and ask for 1 (601) 359-3569 torequest a Complaint Form.  The Complaint Form is also available at http://www.mid.ms.gov/consumers/online-complaint.aspx You may e-mail them at: consumer@mid.ms.gov

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