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:
An appeal can be filed when you do not agree with Molina Healthcare’s decision to:
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:
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. Molina Healthcare also will provide oral language services that includes answering questions in any applicable non-English language and providing assistance with filing claims and appeals (including external review) in any applicable non-English language. You can request that any notice from Molina Healthcare be provided in any applicable non-English language. With respect to any Texas county to which a notice is sent, a non-English language is an applicable non-English language if ten percent (10%) or more of the population residing in the county is literate only in the same non-English language as determined by the Department of Health and Human Services (HHS).
If you appeal Your complaint resolution, We will appoint members to a complaint appeal panel to advise us on the resolution of a disputed decision appealed. The complaint appeal panel will be composed of an equal number of Molina staff members, physicians or other providers, and enrollees. A member of a complaint appeal panel may not have been previously involved in the disputed decision. The physicians or other providers on a complaint appeal panel will have experience in the area of care that is in dispute and must be independent of any physician or provider who made any previous determination. If specialty care is in dispute, the complaint appeal panel will include a person who is a specialist in the field of care to which the appeal relates. The enrollee members of a complaint appeal panel will not be employees of Molina.
An "Adverse Benefit Determination" means a determination by Molina Healthcare that health care services provided or proposed to be provided to a Member are not Medically Necessary or are Experimental or Investigational. A rescission of coverage is also an Adverse Benefit Determination. A rescission does not include a termination of coverage for reasons related to non—payment of premium.
Molina shall provide notice of an adverse determination as follows:
(1) with respect to a patient who is hospitalized at the time of the adverse determination, within one working day by either telephone or electronic transmission to the provider of record, followed by a letter within three working days notifying the patient and the provider of record of the adverse determination;
(2) with respect to a patient who is not hospitalized at the time of the adverse determination, within three working days in writing to the provider of record and the patient; or
(3) within the time appropriate to the circumstances relating to the delivery of the services to the patient and to the patient's condition, provided that when denying post stabilization care subsequent to emergency treatment as requested by a treating physician or other health care provider, the agent shall provide the notice to the treating physician or other health care provider not later than one hour after the time of the request.
The notice of an adverse determination will include:
(1) the principal reasons for the adverse determination;
(2) the clinical basis for the adverse determination;
(3) a description of or the source of the screening criteria used as guidelines in making the adverse determination;
(4) the professional specialty of the physician, doctor, or other health care provider that made the adverse determination;
(5) a description of the procedure for the URA's complaint system as required by §19.1705 of this title (relating to General Standards of Utilization Review);
(6) a description of the URA's appeal process, as required by §19.1711 of this title (relating to Written Procedures for Appeal of Adverse Determination);
(7) a copy of the request for a review by an IRO form, available at www.tdi.texas.gov/forms;
(8) notice of the independent review process with instructions that:
(9) a description of the enrollee's right to an immediate review by an IRO and of the procedures to obtain that review for an enrollee who has a life-threatening condition. If the denial involves a life-threatening condition, the notice will also include a description of Your right to an immediate review by an independent review organization and of the procedures to obtain that review.
In the case of an adverse determination resulting from a retrospective review Molina will provide written notice to the member, within 30 days after the claim is received.
You may request an Appeal of an Adverse Benefit Determination
If Your situation meets the definition of an expedited clinical appeal, You may be entitled to an appeal on an expedited basis. An "expedited clinical appeal" is an appeal of a clinically urgent nature related to health care services, including but not limited to, Prior Authorization for treatment, denial of emergency care or concurrent or continued hospitalization. Before authorization of benefits for an ongoing course of treatment or concurrent or continued hospitalization is terminated or reduced, Molina Healthcare will provide you with notice and an opportunity to appeal. For the ongoing course of treatment, coverage will continue during the appeal process. The procedure will include a review by a health care provider who has not previously reviewed the case and is of the same specialty or a similar specialty as the health care provider who would typically manage the condition under appeal.
Upon receipt of an expedited Prior Authorization or concurrent clinical appeal, Molina Healthcare will notify the party filing the appeal as soon as possible, but in no event later than 24 hours after submission of the appeal, of all the information needed to review the appeal. Molina Healthcare will render a decision on the appeal within 24 hours after it receives the requested information, but no later than 72 hours after the appeal has been received by Molina Healthcare.
An appeal of an Adverse Benefit Determination may be filed by You or a person authorized to act on Your behalf, or Your health care provider. Your designation of a representative must be in writing as it is necessary to protect against disclosure of information about You except to Your authorized representative. To obtain an Authorized Representative Form, You or Your representative may call Molina Healthcare at 1 (888) 560-2025. Molina Healthcare will review its decision in accordance with the following procedure:
For review of claims for payment or reimbursement:Molina Healthcare of Texas, Inc.
For appeal of requests for services, including Prior Authorization:Molina Healthcare of Texas, Inc.
We also will take telephone requests for an appeal. Within 5 working days from the date we receive Your appeal, we will send You a letter acknowledging the date of receipt, the procedures to be followed in the appeal and a list of documents that You must submit for review. When we receive an oral appeal, we will send You a short appeal form. In support of Your appeal, You have the option of presenting evidence and testimony to us. You and Your authorized representative may ask to review Your file and any relevant documents and may submit written issues, comments and additional medical information within 180 days after you receive notice of an Adverse Benefit Determination or at any time during the appeal process. A physician will make the appeal decision.
Molina Healthcare will provide You or Your authorized representative with any new or additional evidence or rationale and any other information and documents used in the review of Your appeal without regard to whether such information was considered in the initial determination.
We will not rely on the initial Adverse Benefit Determination. Any new or additional evidence or rationale will be provided to You or Your authorized representative sufficiently in advance of the date a final decision on appeal is made in order to give You a chance to respond. If the initial benefit determination regarding the claim is based in whole or in part on a medical judgment, the appeal determination will be made by a physician associated or contracted with Molina Healthcare and/or by external advisors, but who were not involved in making the initial denial of Your claim. Before You or Your authorized representative may bring any action to recover benefits the claimant must exhaust the appeal process and must raise all issues with respect to a claim and must file an appeal , and the appeal must be finally decided by Molina Healthcare.
If you have any questions about the appeals procedures, write to us at the above address or call us at 1(866)449-6849 ext. 752054. This appeal process does not prohibit you from pursuing civil action available under the law.
Molina Healthcare will make a determination of the appeal as soon as practical, but in no event more than 30 days after the appeal has been received by us.
Molina Healthcare will notify the party filing the appeal, You, and, any health care provider who recommended the services involved in the appeal, by a written notice of the determination.
The written notice will include:
Your external review rights are described below in the Appeal to an Independent Review Organization (IRO) section below.
You may request an appeal to an Independent Review Organization (“IRO”) of a denial of an appeal of an Adverse Benefit Determination made by Molina Healthcare.
This procedure is not part of the complaint process and pertains only to appeals of Adverse Benefit Determinations. In addition, in life-threatening or urgent care circumstances, You are entitled to an immediate appeal to an IRO and are not required to comply with Molina Healthcare's appeal of an Adverse Determination process.
Any party whose appeal of an Adverse Determination is denied by Molina Healthcare may seek review of the decision by an IRO. At the time the appeal is denied, we will provide You, Your designated representative or Provider of record, information on how to appeal the denial, including any approved form, which You, Your designated representative, or Your provider of record must complete. In life-threatening or urgent care situations, You, Your designated representative, or Your provider of record may contact Molina Healthcare by telephone to request the review and provide the required information. For all other situations, You or Your designated representative must request the IRO review in writing to Molina Healthcare to begin the independent review process.
Upon request and free of charge, You or Your designee may have reasonable access to, and copies of, all documents, records and other information relevant to the claim or appeal, including:
The appeal process does not prohibit You from pursuing other appropriate remedies, including: injunctive relief; a declaratory judgment or other relief available under law, if the requirement to exhaust the process for appeal and review places your health in serious jeopardy.
For more information about the IRO process, call Texas Department of Insurance (TDI) on the IRO information line at (888) TDI-2IRO (834-2476), or in Austin call (512) 322-3400.