Complaints and Appeals

Accessibility

Members that have a problem with any Molina services can contact Molina Complaints and Appeals or send Molina the problem or complaint in writing by mail or filing online.

Definitions

Capitalized terms in the Complaints, Grievances and Appeals section only apply to this section and have the following definitions:

Authorized Representative

An individual authorized in writing by a Member or State Law to act on their behalf in requesting a healthcare service, obtaining claim payment, or during the internal appeal process. A health care provider may act on behalf of a Member without their express consent when it involves an Urgent Care Service.

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 is a Final Adverse Benefit Determination.

Independent Review Organization (IRO)

An organization renders an independent and impartial decision on a Final Adverse Benefit Determination.

Post-Service Claim

Molina rendered an Adverse Benefit Determination for a service that completed.

Pre-Service Claim

Molina rendered an Adverse Benefit Determination and the requested service was not completed.

UID

The Utah Insurance Department and Office of the Commissioner.

Urgent Care Services Claim

Molina rendered an Adverse Benefit Determination and the requested service did not complete, where the application of non-Urgent Care appeal periods could seriously jeopardize: a Member's life or health or that of their unborn child; or in the opinion of the treating Provider, would subject a Member to severe pain unless a Member receives the care or treatment that is the subject of the Internal Appeal.

Members that have a problem with any Molina services can contact Molina Customer Support or send Molina the problem or complaint in writing by mail or filing online.

Complaint and Appeals Contact Information:
Molina Complaints and Appeals
7050 Union Park Center, Suite 200
Midvale, UT, 84047
Website: MolinaMarketplace.com
Toll-Free Phone: 1 (888) 858-3973. TTY users may dial 711
or
Utah Insurance Department Consumer Services
Suite 3110 State Office Building Salt Lake City UT 84114 1 (801) 538-3077
E-mail: healthappeals.uid@utah.gov

Complaint

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 Member's doctor. Issues relating to the denial of healthcare services are Appeals and should be filed by mail, phone or online with Molina or the Utah Insurance Department (UID). Molina will respond to a Member complaint no later than 60 days from receipt of the Complaint.

Member Grievance/Appeal Request Form

Internal Appeal

A Member, Member's Authorized Representative, or a treating Provider or facility may submit an appeal of an Adverse Benefit Determination . Molina will provide the Member with the forms necessary to initiate an appeal. A Member may request these forms by contacting Molina Complaints and Appeals. While Member's are not required to use Molina's forms, Molina strongly encourages that an appeal be submitted on such form to facilitate logging, identification, processing, and tracking of the appeal through the review process. If a Member need assistance in preparing the appeal, or in submitting an appeal verbally, a Member may contact Molina for such assistance. A Member or their Authorized Representatives must file an appeal within 180 days from the date of the notice of Adverse Benefit Determination . Within 5 business days of receiving an appeal, Molina will send a Member or their Authorized Representative a letter acknowledging receipt of the appeal. Member's coverage will remain in effect pending the outcome of their internal 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 healthcare professionals in the same or similar specialty as typically manages the type of medical service under review.

Timeframe

Molina will respond to the following types of appeal requests in the following time frames:

  • Urgent Care Services: Within 72 hours
  • Pre-Service Claim: Within 30 days
  • Concurrent service (a request to extend or a decision to reduce a previously approved course of treatment): Within 72 hours for in-network
  • Post-Service Claim: Within 60 days

Exhaustion of Process

The preceding procedures and processes are mandatory and must be exhausted prior to establishing litigation or any administrative proceeding regarding matters within the scope of this “” section.

General Rules and Information

A Member must cooperate fully with Molina to promptly review and resolve a complaint or appeal. In the event a Member does not fully cooperate with Molina, it will be deemed that the Member has waived their right to have the Complaint or Appeal processed within the periods set forth above. Molina will offer to meet with a Member by telephone or in person. Molina will make appropriate arrangements to allow telephone conferencing or an in-person meeting upon request at Molina administrative offices. Molina will make these arrangements with no additional charge to a Member. During the review process, Molina will review the services in question without regard to the decision reached in the initial determination. Molina will provide the Member with new or additional informational evidence that it considers, relies upon, or generates in connection with an appeal that was not available when Molina made the initial Adverse Benefit Determination . A "full and fair" review process requires Molina to send any new medical information to review directly so a Member have an opportunity to review the claim file.

Independent Review Process

A Member may request an independent review of an Adverse Benefit Determination only after exhausting the Molina's internal review process described above unless: (1) Molina agrees to waive the internal review process; (2) Molina has not complied with the requirements of the internal review process, except where those failures are de minimus 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) a Member has requested an expedited independent review at the same time.

Molina will pay the cost for an IRO to conduct a review of an Adverse Benefit Determination . A Member may request an independent review at regardless of the dollar amount of the claim or services involved. A Member must file a request with UID for an independent review no later than 180 days after a Member receives the Final Adverse Benefit Determination notice from Molina. If a Member sends the request to Molina, Molina will forward the request to the UID within 1 business day of receipt. A Member must use the Independent Review Request Form available at www.insurance.utah.gov or from Molina Complaints and Appeals Unit to file the request. The independent review request must contain an authorization for the necessary parties to obtain medical records for purposes of deciding on the independent review request. The independent review decision is binding on Molina and the Member except to the extent that other remedies are available under federal law and State Laws.

Upon receipt of the Independent Review Request Form, UID will send a copy of the request to Molina. Within 5 business days following receipt of the request, Molina will determine whether (a) the individual was a Member at the time of rescission or the healthcare service was requested or provided; (b) a healthcare service that is the subject of an Adverse Benefit Determination is a Covered Service; (c) the Member has exhausted Molina's internal review process described above; and (d) the Member has provided all the information and forms required for the independent review. Within 1 business day of making these determinations, Molina will notify UID and the Member in writing whether the request is complete and eligible for independent review. If the request is not complete, Molina will inform the Member and UID in writing what information or materials are needed to make the request complete. If the request is not eligible for independent review, Molina will inform the Member and UID in writing of the reasons why the request is not eligible for independent review and inform the Member that the determination may be appealed to UID. UID may decide in accordance with the terms of this Agreement that the request is eligible for independent review despite Molina'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, UID will:

  • Assign on a random basis an IRO from the list of approved IROs based on the nature of the healthcare service that is subject to review;
  • Notify Molina of the assignment and require Molina to provide to the IRO the documents and any information considered in making the Adverse Benefit Determination within 5 business days; and
  • Notify the Member that the request has been accepted and the Member may submit additional information to the IRO within 5 business days of receipt of the UID's notice.

The IRO will forward to Molina within 1 business day of receipt any information submitted by the Member. The IRO will provide notice of its decision to uphold or reverse the Adverse Benefit Determination within 45 calendar days to the Member, Molina and UID. 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 1 business day of the notice.

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, UID will immediately send a copy of the request to Molina. Immediately upon receipt, Molina will determine whether:

  1. the individual was a Member at the time the healthcare service was requested or provided;
  2. a health care service that is the subject of an Adverse Benefit Determination is a Covered Service; and
  3. the Member has provided all the information and forms required for the expedited independent review. Molina will immediately notify the UID and the Member whether the request is complete and eligible for expedited independent review.

If the request is not complete, Molina will inform the Member and the UID in writing what information or materials are needed to make the request complete. If the request is not eligible for expedited independent review, Molina Healthcare will inform the Member and UID in writing of the reasons why the request is not eligible for expedited independent review and inform the Member that the determination may be appealed to UID. UID may decide in accordance with the terms of this Agreement that the request is eligible for expedited independent review despite Molina'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 UID will:

  • Assign on a random basis an IRO from the list of approved IRO based on the nature of the health care service that is subject to review;
  • Notify Molina of the assignment and require Molina within five days to provide to the IRO the documents and any information considered in making the Adverse Benefit Determination; and
  • Notify the Member that the request has been accepted and the Member may submit additional information to the IRO within five days of receipt of the UID's notice.

The IRO will forward to Molina within 1 business day of receipt any information submitted by the Member. The IRO 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 the Member, Molina and UID. If the notice is not in writing, the IRO 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 will approve the coverage that was the subject of the Adverse Benefit Determination and process any benefit that is due within 1 business day of the notice.

Independent Review Requests Based on Experimental or Investigational Services

If a Member submits a request for independent review involving Experimental or Investigational Services, the request must contain a certification from the Member's Provider that (a) standard health care service or treatment has not been effective in improving the Member's condition; (b) standard healthcare services or treatments are not medically appropriate for the Member; or (c) there is no available standard healthcare 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 investigation services or treatments, the UID will send a copy of the request to Molina. Within 5 business days, or 1 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) the Member has exhausted Molina's internal review process described above, unless the request is for an expedited review; 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 UID and the Member in writing whether the request is complete and eligible for independent review. If the request is not complete, Molina Healthcare will inform the Member and the UID 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 the Member and the UID in writing of the reasons why the request is not eligible for independent review and inform the Member that the determination may be appealed to the Utah Insurance Commissioner. The UID 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 UID will the request will be independently reviewed. If a request is eligible for independent review, the UID will:

  • Assign on a random basis an IRO from the list of approved IRO based on the nature of the health care service that is subject to review;
  • Notify Molina Healthcare of the assignment and require Molina within five business days, or one business day for a request for expedited review, to provide to the IRO the documents and any information considered in making the Adverse Benefit Determination ; and
  • Notify the Member that the request has been accepted and the Member may submit additional information to the IRO within 5 business days, or one business day for expedited review requests, of receipt of the Utah Insurance Commissioner's notice. The IRO will forward to Molina within 1 business day of receipt any information submitted by the Member. Within one business day of receipt of the request, the IRO will select a one or more clinical reviews to conduct the review. The clinical reviewer will provide the IRO a written opinion with 20 calendar days, or 5 calendar days for an expedited review, after being selected. The IRO will decide 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 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

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