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.

COMPLAINTS AND APPEALS

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 us at (888) 858-3973, Monday through Friday, 8:00 a.m. - 6:00 p.m. MT. Deaf or hard of hearing Members may call our toll-free TTY number at (800) 346-4128 or 711.

Send us your problem or complaint in writing.
Our address is:

Molina Healthcare of Utah, Inc.

Attn: Complaints and Appeals Coordinator

PO Box 182273

Chattanooga, TN 37422

Contact the Utah Insurance Department Consumer Services

Utah Insurance Commissioner

Suite 3110

State Office Building

Salt Lake City UT 84114

801 538-3077

healthappeals.uid@utah.gov

Fill out our Member Grievance/Appeal Request Form and send it to us in the mail.

Molina recognizes the fact that You 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 concerns and any complaints You may have. We will respond to Your complaint no later than 60 days from when We receive it.
         

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, is not an Adverse Benefit Determination.

“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.

“UID”: means the Utah Insurance Department.

“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

Your, 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 at the telephone number listed on the Member ID card. While You are not required to use Molina’s pre-printed form, Molina 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.

If You need assistance in preparing the appeal, or in submitting an appeal verbally, You may contact Molina for such assistance at: 

Molina Healthcare of Utah, Inc.

Attn: Grievance and Appeals Coordinator

PO Box 182273

Chattanooga, TN 37422
         

If You are Hearing impaired You may also contact Molina via the National Relay Service at 711.

You (or Your Authorized Representatives) must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination.

Within five 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.

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’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, You will be deemed to have waived Your right to have the Complaint or Appeal processed within the time frames set forth above.
• Molina 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 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 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 Complaints 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 complaints and appeals.

Utah Insurance Commissioner

Suite 3110

State Office Building

Salt Lake City UT 84114

801 538-3077

healthappeals.uid@utah.gov

Molina Healthcare of Utah, Inc.

Attn: Complaints and Appeals Coordinator

PO Box 182273

Chattanooga, TN 37422

www.molinahealthcare.com
         

INDEPENDENT REVIEW PROCESS

You may request an independent review of an Adverse Benefit Determination 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 review process, except where those failures are de minimis violations that do not cause, and are not likely to cause, prejudice or harm to the Member and are not part of a pattern or practice failing to follow the requirements; or (3) You have requested an expedited independent review at the same time You requested an expedited internal review.

Rules That Apply to All Independent Review Requests

Molina will pay the cost for an independent review organization to conduct a review of an Adverse Benefit Determination. You may request an independent review at regardless of the dollar amount of the claim or services involved.

You must file a request with the Utah Insurance Commissioner for an independent review no later than 180 days after You receive the Final Adverse Benefit Determination notice from Molina Healthcare. If You send the request to Molina Healthcare, we will forward the request to the Utah Insurance Commissioner within 1 business day of receipt. You must use the Independent Review Request Form available at www.insurance.utah.gov, or from the Customer Support Center at (800) 858-3973 to file the request.

The independent review request must contain an authorization for the necessary parties to obtain medical records for purposes of making a decision on the independent review request.

The independent review decision is binding on Molina Healthcare and the Member except to the extent other remedies are available under federal and state laws.

Rules That Apply to a Standard Independent Review Request

Upon receipt of the Independent Review Request Form, the Utah Insurance Commissioner will send a copy of the request to Molina Healthcare. Within five business days following receipt of the request, Molina will determine whether: (a) the individual was a Member at the time of rescission or the health care service was requested or provided; (b) a health care service that is the subject of an Adverse Benefit Determination is a covered service; (c) the Member has exhausted Molina Healthcare’s internal review process described above; and (d) the Member has provided all the information and forms required for the independent review.

Within one business day of making these determinations, Molina Healthcare will notify the Utah Insurance Commissioner and You in writing whether the request is complete and eligible for independent review. If the request is not complete, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing what information or materials are needed to make the request complete.

If the request is not eligible for independent review, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing of the reasons the request is not eligible for independent review and inform the Member that the determination may be appealed to the Utah Insurance Commissioner. The Utah Insurance Commissioner may decide in accordance with the terms of this EOC that the request is eligible for independent review despite Molina Healthcare’s determination that the request is not eligible in which case the request will be independently reviewed.

If a request is eligible for independent review, the Utah Insurance Commissioner will:

• Assign on a random basis an independent review organization from the list of approved independent review organizations based on the nature of the health care service that is subject to review;
• Notify Molina Healthcare of the assignment and require Molina Healthcare to provide to the independent review organization within 5 business days the documents and any information considered in making the Adverse Benefit Determination; and
• Notify You that the request has been accepted and You may submit additional information to the independent review organization within 5 business days of receipt of the Utah Insurance Commissioner’s notice. The independent review organization will forward to Molina Healthcare within 1 business day of receipt any information submitted by You.

The independent review organization will provide notice of its decision to uphold or reverse the Adverse Benefit Determination within 45 calendar days to You, Molina Healthcare and the Utah Insurance Commissioner. If the Adverse Benefit Determination is reversed, Molina Healthcare will approve the coverage that was the subject of the Adverse Benefit Determination and process any benefit that is due within one business day of the notice.

Rules that Apply to Expedited Independent Review Requests

An expedited independent review is available when 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;
• In the opinion of the Member’s attending provider, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the Adverse Benefit Determination; or
• Concerns an admission, availability of care, continued stay or health care service for which the Member received Emergency Services, but has not been discharged from a facility.

Upon receipt of the Independent Review Request Form, the Utah Insurance Commissioner will immediately send a copy of the request to Molina Healthcare. Immediately upon receipt, Molina Healthcare will determine whether : (a) the individual was a Member at the time the health care service was requested or provided; (b) a health care service that is the subject of an Adverse Benefit Determination is a covered service; and (c) the Member has provided all the information and forms required for the expedited independent review.

Molina Healthcare will immediately notify the Utah Insurance Commissioner and You whether the request is complete and eligible for expedited independent review. If the request is not complete, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing what information or materials are need to make the request complete.

If the request is not eligible for expedited independent review, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing of the reasons why the request is not eligible for expedited independent review and inform You that the determination may be appealed to the Utah Insurance Commissioner. The Utah Insurance Commissioner may decide in accordance with the terms of this EOC that the request is eligible for expedited independent review despite Molina Healthcare’s determination that the request is not eligible in which case the request will be independently reviewed

If a request is eligible for expedited independent review, the Utah Insurance Commissioner will:

• Assign on a random basis an independent review organizations from the list of approved independent review organization based on the nature of the health care service that is subject to review;
• Notify Molina Healthcare of the assignment and require Molina Healthcare within 1 business day to provide to the independent review organization the documents and any information considered in making the Adverse Benefit Determination; and
• Notify You that the request has been accepted and You may submit additional information to the independent review organization within 1 business day of receipt of the Utah Insurance Commissioner’s notice. The independent review organization will forward to Molina Healthcare within 1 business day of receipt any information submitted by You.

The independent review organization will, as soon as possible, but not later than 72 hours after receipt of the request for an expedited independent review, provide notice of its decision to uphold or reverse the Adverse Benefit Determination to You, Molina Healthcare and the Utah Insurance Commissioner. If the notice is not in writing, the independent review organization must provide written confirmation of its decision within 48 hours after the date of notification of the decisions. If the Adverse Benefit Determination is reversed, Molina Healthcare will approve the coverage that was the subject of the Adverse Benefit Determination and process any benefit that is due within one business day of the notice.

Rules that Apply to Independent Review Requests Based on Experimental or Investigational Services or Treatments

If You submit a request for independent review involving experimental or investigational service or treatment, the request must contain a certification from the Member’s physician that: (a) standard health care service or treatment has not been effective in improving the Member’s condition; (b) standard health care services or treatments are not medically appropriate for the Member; or (c) there is no available standard health care service or treatment covered by the Plan that is more beneficial than the recommended or requested health care service or treatment.

Upon receipt of the Independent Review Request Form involving experimental or investigational services or treatments, the Utah Insurance Commissioner will send a copy of the request to Molina Healthcare. Within five business days, or one business day for expedited requests, following receipt of the request, Molina will determine whether : (a) the individual was a Member at the time the health care service was requested or provided; (b) the health care service that is the subject of an Adverse Benefit Determination is a covered service, except that the service or treatment is experimental or investigational for a particular medical condition and is not explicitly listed as an excluded benefit in the EOC; (c) You have exhausted Molina’s internal review process described above, unless the request is for an expedited review; and (d) You have provided all the information and forms required for the independent review.

Within one business day of making these determinations, Molina Healthcare will notify the Utah Insurance Commissioner and You in writing whether the request is complete and eligible for independent review. If the request is not complete, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing what information or materials are needed to make the request complete.

If the request is not eligible for independent review, Molina Healthcare will inform You and the Utah Insurance Commissioner in writing of the reasons why the request is not eligible for independent review and inform You that the determination may be appealed to the Utah Insurance Commissioner. The Utah Insurance Commissioner may decide in accordance with the terms of this EOC that the request is eligible for independent review despite Molina Healthcare’s determination that the request is not eligible in which case the request will be independently reviewed.

If a request is eligible for independent review, the Utah Insurance Commissioner will:

• Assign on a random basis an independent review organizations from the list of approved independent review organization based on the nature of the health care service that is subject to review;
• Notify Molina Healthcare of the assignment and require Molina Healthcare within five business days, or one business day for a request for expedited review, to provide to the independent review organization the documents and any information considered in making the Adverse Benefit Determination; and
• Notify You that the request has been accepted and You may submit additional information to the independent review organization within 5 business days, or one business day for expedited review requests, of receipt of the Utah Insurance Commissioner’s notice. The independent review organization will forward to Molina Healthcare within one business day of receipt any information submitted by You.

Within one business day of receipt of the request, the independent review organization will select one or more clinical reviewers to conduct the review. The clinical reviewer will provide the independent review organization a written opinion within 20 calendar days, or five calendar days for an expedited review, after being selected.

The independent review organization will make a decision based on the clinical reviewer’s opinion within 20 calendar days of receipt of the opinion, or 48 hours in the case of an expedited review, and provide notice of its decision to the Member, Molina and the Utah Insurance Commissioner. If the Adverse Benefit Determination is reversed, Molina will approve the coverage that was the subject of the Adverse Benefit Determination and process any benefit that is due within one business day of the notice.