Complaints and Appeals

Accessibility

Complaints

A complaint is any dissatisfaction that a Member has with Molina or any Participating Provider that is not related to the denial of healthcare services. For example, a Member may be dissatisfied with the hours of availability of a Participating Provider. Issues relating to the denial of health care services are Appeals and should be filed with Molina or the Ohio Department of Insurance in the manner described in the Internal Appeals section below. Molina recognizes the fact that a Member may not always be satisfied with the care and services provided by our Participating Providers. Molina wants to know about concerns and any complaints Members may have. Molina will respond to a Member complaint no later than 60 days from the date Molina received it. A Member may contact Molina for assistance with filing a complaint over the phone, by mail or fax using the following contact information.

Molina Appeals and Grievances Department Address:
Molina Healthcare of Ohio, Inc. Appeals and Grievance Department
P.O. Box 349020 Columbus, Ohio 43234-9020
Phone: (888) 296-7677, Monday – Friday 7:00 am – 7:00 pm EST
TTY: (800) 750-0750 or 711
Website: www.molinahealthcare.com

Member may also contact the Ohio Department of Insurance, Ohio Department of Insurance Consumer Affairs Address: Ohio Department of Insurance ATTN: Consumer Affairs

50 West Town St. Suite 300
Columbus, Ohio 43215
Phone: (800) 686-1526
Phone: (614) 644-2673
Fax: (614) 644-3744 TTY: (614) 644-3745
Website: https://www.insurance.ohio.gov/Pages/ default.aspx
File Online Consumer Complaint: http://insurance.ohio.gov/Consumer/OCS/Pages/ConsCompl.aspx

Definitions

For the purposes of this section, the following definitions apply:

Final Adverse Benefit Determination

An Adverse Benefit Determination that is upheld after the internal appeal process. If the period allowed for the internal appeal elapses without a determination by Molina, then the internal appeal will be deemed a Final Adverse Benefit Determination.

Appointing a Representative

If a Member would like someone to act on their behalf regarding a claim or an appeal of an Adverse Benefit Determination, the Member may appoint an authorized representative. Members should send the representative's name, address, and telephone contact information to the Molina Appeals and Grievances Department Address, listed in the Complaints section. Members must pay the cost of anyone the Member hires to represent or help the Member.

Claim Decisions

After a determination on a claim is made, Molina will notify the Member of its determination within the following timeframes:

Title of the table
Request Type Timeframe for Decision and Notification
Pre-Service Claim Within 48 hours for Urgent Care services, or 10 calendar days for any Prior Authorization request that is not for an Urgent Care Service, of the time the request is received. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform the Member of the reason for denial.)
Concurrent Service Claim 24 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform the Member of the reason for denial.)
Post-Service Claim 30 days from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform the Member of the reason for denial.)
Please Note: Additional information requests for Urgent Care Services will be made within 24 hours in accordance with State Law.

If Medical Necessity is determined on Appeal and a Prior Authorization is required for the benefit, the determination will also include the authorization of the benefit in the determination

Urgent Care Service Claim

A claim involving Urgent Care Services is processed as timely as possible given the circumstances and will always be processed within no more than 48 hours from receipt of request (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform Member of the reason for denial.), or if shorter, the period required under Section 2719 of the federal Public Health Services Act and subsequent rules and regulations.

Initial Denial Notices

Written notice of an Adverse Benefit Determination (including a partial claim denial) will be provided to Member within the time frames noted within this section. With respect to Adverse Benefit Determinations involving an Urgent Care Service, notice may be provided to Member orally within the timeframes noted within this section. If oral notice is given, written notification must be provided no later than 3 days after oral notification.

An Adverse Benefit Determination notice will identify the claim involved, convey the specific reason for the Adverse Benefit Determination (including the denial code and its meaning), the specific provisions upon which Molina based the determination, and the contact information for the Ohio Department of Insurance, which is available to assist Member with the internal and external appeal processes. The notice will also include a description of any additional information necessary to perfect the claim and an explanation of why such information is necessary.

The notice will disclose if any internal policy, protocol, or similar criterion was relied upon to deny the claim. A copy of the policy, protocol, or similar criterion will be provided to Member, free of charge. In addition to the information provided in the notice, Members have the right to request the diagnosis, treatment codes and descriptions upon which the determination is based. The notice will describe Molina's review procedures and the time limits applicable to such procedures following an Adverse Benefit Determination on review.

If an Adverse Benefit Determination is based on Medical Necessity, Experimental or Investigational treatment or similar exclusion or limitation, the notice will provide an explanation of the scientific or clinical basis for the determination, free of charge. The explanation will apply the terms of the product to Member medical circumstances. In the case of an Adverse Benefit Determination involving a claim for Urgent Care Service, the notice will provide a description of Molina's expedited review procedures, which Molina describes below.

Internal Appeals

Members must appeal an Adverse Benefit Determination within 180 days after receiving written notice of the denial (or partial denial). Members may appeal an Adverse Benefit Determination by means of written notice to Molina, in person, orally, or by mail, postage prepaid. Adverse Benefit Determinations for electronic Prior Authorizations are included. Member Appeals should include:

  • The date of the Member Appeal
  • Member name (please print or type).
  • The date of the service Molina denied
  • Member identification number, claim number, and Provider name as shown on the explanation of benefits

Members should keep a copy of the Appeal for their records because no part of it can be returned to Member. Members may request an expedited internal appeal of an Adverse Benefit Determination involving an Urgent Care Services orally or in writing. In such case, all necessary information will be transmitted between Molina and the Member by telephone, fax, or other available similarly expeditious method, to the extent permitted by applicable law. Members may also request an expedited external review of an Adverse Benefit Determination involving an Urgent Care Service at the same time a request is made for an expedited internal appeal of an Adverse Benefit Determination if the Member's Provider certifies that the Adverse Benefit Determination involves a medical condition that could seriously jeopardize the Member's life or health, or would jeopardize the Member's ability to regain maximum function if treated after the time frame of an expedited internal appeal (i.e.,72 hours). Members may not file a request for expedited external review unless Members also file an expedited internal appeal. Determination of appeals of Adverse Benefit Determinations will be conducted promptly, will not defer to the initial determination, and will not be made by the person who made the initial Adverse Benefit Determination or a subordinate of that person. The determination will consider all comments, documents, records, and other information submitted by the Member relating to the claim.

On appeal, Member may review relevant documents, request copies of any relevant information (which will be provided free of charge) and may submit issues and comments in writing. Upon request, Members may also discover the identity of medical or vocational experts whose advice was obtained on behalf of Molina in connection with the Adverse Benefit Determination being appealed, as permitted under applicable law.

If Molina bases the Adverse Benefit Determination in whole, or in part, upon a medical judgment, including determinations as to whether a particular treatment, drug, or other service is Experimental or Investigational, or not Medically Necessary or appropriate, the person deciding the appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The consulting health care professional will not be the same person who decided the initial appeal or a subordinate of that person.

If new or additional evidence is relied upon or if new or additional rationale is used during the internal appeal process, Molina will provide to Members, free of charge, the evidence or rationale as soon as possible and in advance of the appeals decision in order to provide Member a reasonable opportunity to respond. However, if Molina receive the new or additional evidence so late that it would be impossible to provide it to Member in time for Member to have a reasonable opportunity to respond, the period for providing notice of Molina's appeal decision will be tolled until the Member has a reasonable opportunity to respond. After a Member responds or has a reasonable opportunity to respond but fails to do so, Molina will notify the Member of Molina's decision as soon as reasonably possible, considering the medical circumstances. Member coverage will remain in effect pending the outcome of Member internal appeal.

Timeframes for Decisions on Appeal

For appeals of Adverse Benefit Determinations, Molina will make decisions and provide notice of the decisions as follows:

Title of the table
Timeframe for Appeal Response
Request Type Timeframe for Decision
Urgent Care Service Decisions Within 48 hours from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform the Member of the reason for denial.)
Pre-Service and Post-Service Decisions Within 30 days from receipt of request. (If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform the Member of the reason for denial.)

An Urgent Care appeal or claims involving Urgent Care Services are processed as timely as possible given the circumstances and will always be processed within no more than 48 hours from receipt of requestor, if shorter, the period required under Section 2719 of the federal Public Health Services Act and subsequent rules and regulations. If all information reasonably necessary and requested by Molina is not received in this timeframe this may result in a denial. Molina will inform Member of the reason for denial.

Appeals Denial Notices

Notice of a Final Adverse Benefit Determination (including a partial denial) will be provided to the Member by mail, postage prepaid, by fax or by e-mail, as appropriate and as required by State Law, within the time periods noted above. A notice that Molina have denied a claim appeal will include:

  • Enough information to identify the claim involved;
  • The specific reason or reasons for the Final Adverse Benefit Determination, including the denial code and its meaning;
  • Reference to the specific product provision upon which the determination is based;
  • A statement that Member is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to Member claim for benefits;
  • If Molina relied upon any internal Molina policy, protocol or similar criterion to deny the claim, then a copy of the policy, protocol or similar criterion will be provided to Member, free of charge, along with a discussion of the decision;
  • A statement of Member right to external review, a description of the external review process, and the forms for submitting an external review request, including release forms authorizing Molina to disclose protected health information pertinent to the external review; and
  • If Molina bases a Final Adverse Benefit Determination on Medical Necessity, Experimental or Investigational treatment or similar exclusion or limitation, the notice will provide:
    • An explanation of the scientific or clinical basis for the determination, free of charge. The explanation will apply the terms of this Agreement to Member medical circumstances.
    • A notice of voluntary alternative dispute resolution options, as applicable

For assistance with appeals, complaints or the external review process, a Member may write or call the Ohio Department of Insurance Office of Consumer Affairs via the contact methods identified in this section. In addition to the information provided in the notice, Members have the right to request the diagnosis and treatment codes and descriptions upon which the determination is based.

External Review

After Members receive a Final Adverse Benefit Determination or if Members are otherwise permitted, as described above, Members may request an external review if a Member believes that a healthcare service has been improperly denied, modified, or delayed on the grounds that the healthcare service doesn't meet Molina's requirements for Medical Necessity, appropriateness, healthcare setting, level of care, effectiveness of a covered benefit, or is Experimental or Investigational.

An external review may be conducted by an Independent Review Organization (IRO) for Final Adverse Benefit Determinations involving Medical Necessity or medical judgment or by the Ohio Department of Insurance if the Final Adverse Benefit Determination involves a determination that the medical service is not covered by this Agreement. Molina will not choose or influence the IRO's reviewers. Members' coverage will remain in effect pending the outcome of the external review.

There are three types of IRO reviews:

  1. standard external review,
  2. expedited external review, and
  3. external review of Experimental or Investigational treatment.

Standard External Review

A standard external review is normally completed within 30 days.

Expedited External Review

An expedited review for urgent medical situations, including reviews of Experimental or Investigational treatment involving an urgent medical situation are normally completed within 72 hours and can be requested if any of the following applies:

  • Member's Provider certifies that the Adverse Benefit Determination or Final Adverse Benefit Determination involves a medical condition that could seriously jeopardize Member life or health or would jeopardize Member ability to regain maximum function if treatment is delayed until after the time frame of an expedited internal appeal or a standard external review
  • The Adverse Benefit Determination or Final Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care service for which Member received Emergency Services, but have not yet been discharged from a facility; or
  • An expedited internal appeal is in process for an Adverse Benefit Determination of Experimental or Investigational treatment and Member's Provider certifies in writing that the recommended health care service or treatment would be significantly less effective if not promptly initiated.

External Review of Experimental and Investigational Treatment

Requests for standard or expedited external reviews that involve Adverse Benefit Determinations or Final Adverse Benefit Determinations for treatments that are Experimental or Investigational may proceed if the Member's Provider certifies one of the following:

  • Standard health care services have not been effective in improving Member condition,
  • Standard health care services are not medically appropriate for Member, or
  • No available standard health care service covered by Molina is more beneficial than the requested health care service

Request for External Review in General

Members must request an external review within 180 days of the date of the notice of Adverse Benefit Determination or Final Adverse Benefit Determination issued by Molina. All requests must be in writing, except for a request for an expedited external review. Expedited external reviews may be requested electronically or orally. If the request is complete, Molina will initiate the external review and notify Members in writing that the request is complete and eligible for external review. The notice will include the name and contact information for the assigned IRO or the Ohio Department of Insurance (as applicable) for the purpose of submitting additional information. The notice will also inform Members that, within 10 business days after receipt of the notice, Members may submit additional information in writing to the IRO or the Ohio Department of Insurance (as applicable) for consideration in the review.

Molina will also forward all documents and information used to make the Adverse Benefit Determination to the assigned IRO or the Ohio Department of Insurance (as applicable). If the request is not complete Molina will inform Members in writing and specify what information is needed to make the request complete. If Molina determines that the Adverse Benefit Determination is not eligible for external review, Molina will notify Members in writing, provide Members with the reason for the denial, and inform Members that the denial may be appealed to the Ohio Department of Insurance. The Ohio Department of Insurance may determine the request is eligible for external review regardless of the decision by Molina and require that the request be referred for external review. The Department's decision will be made in accordance with the terms of this Agreement and State Law. Molina will pay the costs of the external review.

IRO Assignment

The Ohio Department of Insurance maintains a secure web-based system that is used to manage and monitor the external review process. When Molina initiates an external review by an IRO in this system, the Ohio Department of Insurance system randomly assigns the review to an Ohio accredited IRO that is qualified to conduct the review based on the type of health care service. Molina and the IRO are automatically notified of the assignment.

IRO Review and Decision

The IRO must forward, upon receipt, any additional information it receives from Members to Molina. At any time, Molina may reconsider its Adverse Benefit Determination and provide coverage for the healthcare service. Reconsideration will not delay or terminate the external review. If Molina reverses the Adverse Benefit Determination, Molina will notify Members, the assigned IRO and the Ohio Department of Insurance within 1 day of the decision. Upon receipt of the notice of reversal by Molina, the IRO will terminate the review.

In addition to all documents and information considered by Molina in making the Adverse Benefit Determination, the IRO must consider things such as; Members' medical records, the attending healthcare professional's recommendation, consulting reports from appropriate healthcare professionals, the terms of this Agreement and the most appropriate practice guidelines.

The IRO will provide a written notice of its decision within 30 days of receipt by Molina of a request for a standard review or within 72 hours of receipt by Molina of a request for an expedited review. This notice will be sent to Members, Molina and the Ohio Department of Insurance and must include the following information:

  • A general description of the reason for the request for external review
  • The date the independent review organization was assigned by the Ohio Department of Insurance to conduct the external review
  • The dates over which the external review was conducted
  • The date on which the independent review organization's decision was made
  • The rationale for its decision
  • References to the evidence or documentation, including any evidence-based standards, that was used or considered in reaching its decision

Binding Nature of External Review Decision

An external review decision is binding on Molina except to the extent Molina has other remedies available under State Law. The decision is also binding on Members except to the extent that Members has other remedies available under applicable State Law or federal law. Members may not file a subsequent request for an external review involving the same Adverse Benefit Determination that was previously reviewed unless new medical or scientific evidence is submitted to Molina. If Members have questions about Members' rights or need assistance, Members may contact the Ohio Department of Insurance Consumer Affairs address in this provided in this section.

Ohio Department of Insurance External Review

Members may request an external review of a Final Adverse Benefit Determination by the Ohio Department of Insurance if Members believe that a healthcare service has been improperly denied, modified, or delayed on the grounds that the healthcare service is not covered under this Agreement or Members are denied an external review of an Adverse Benefit Determination or Final Adverse Benefit Determination. Members may contact Molina to request an external review.

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