"Adverse Benefit Determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including a denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member's or applicant's eligibility to participate in this plan, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or appropriate.
"External Review of Adverse Benefit Determination" means a request by a Member or the Member's designated representative for an Independent Review Organization to determine whether Molina's Internal Review decisions are correct.
"Final External Review Decision" means a determination by an Independent Review Organization at the conclusion of an External Review of an Adverse Benefit Determination.
"Final Internal Adverse Benefit Determination" means an Adverse Benefit Determination that has been upheld by Molina at the completion of the Internal Review or Appeal process, or an Adverse Benefit Determination for which the Internal Review or Appeal process has been exhausted.
"Grievance" also called a complaint, means a verbal or written complaint submitted by or on behalf of a Member regarding service delivery issues other than denial of payment for, or non-provision of, medical services, including dissatisfaction with medical care, waiting time for medical services, Provider or staff attitude or dissatisfaction with the service provided by Molina.
"Independent Review Organization" means a certified independent review organization established by the Washington State Insurance Commissioner that is not affiliated with Molina.
"Internal Review of Adverse Benefit Determination" means the request by or on behalf of a Member to review and reconsider an Adverse Benefit Determination.
For any problem with any Molina Healthcare services, Molina wants to help fix it. Molina recognizes the fact that Members may not always be satisfied with the care and services provided by Molina's contracted doctors, hospitals and other Providers. Molina wants to know about any problems and/or complaints. Members may file a Grievance (also called a complaint) in person, in writing, or by telephone. Grievances must be filed within one hundred eighty (180) calendar days from the day the incident or action occurred which caused the dissatisfaction. Molina will never retaliate against a Member in any way for filing a Grievance.
Molina will send a letter acknowledging receipt of the Member's Grievance within 72 hours of receipt of the request. Grievances will be resolved within thirty (30) calendar days.
Members who receive an Adverse Benefit Determination can file a request for an internal review of the Adverse Benefit Determination. Molina will process written or oral requests for an internal review of an Adverse Benefit Determination, also called an Appeal. There are two levels of appeals, an Internal Review of an Adverse Benefit Determination and an External Review of an Adverse Benefit Determination. When the Internal Review is final, Members may request an External Review of the Final Internal Adverse Benefit Determination as explained below.
Requests for Internal Review or Appeal of Adverse Benefit Determinations must be received within 180 calendar days of receipt of an Adverse Benefit Determination. Requests for Internal Review or Appeals may be made by calling Molina's Customer Support at the number shown in the Reference Guide on page 2 of this Agreement. Appeals can also be filed in writing to the Customer Support address shown in the Reference Guide on page 2 of this Agreement.
Molina will send a letter acknowledging receipt of the request for Internal Review or Appeal within 72 hours of receipt of the request. Molina's Internal Review or Appeal procedures will be completed within fourteen (14) calendar days for Adverse Benefit Determinations and twenty calendar (20) days for appeals involving Experimental and Investigational procedures. We may extend the time it takes to make a decision by up to 16 additional days if Molina notifies the Member of the extension and the reason for the extension. Any further extensions by Molina are subject to the Member's informed written consent to an extension. An extension will not extend the time for a determination beyond twenty (20) calendar days without the Member's written consent.
Members may submit information, comments, records, and other items to assist in the review. In addition, Members may review and copy Molina's records and information relevant to the claim free of charge. Molina will consider all information submitted prior to making a determination. Our review will be performed by persons who were not involved in the original decision and if the Adverse Benefit Determination involved medical judgement, the reviewer will be someone who is or consults with, a health care professional who has appropriate training and experience in the field of medicine encompassing the condition or disease and make a determination that is within the clinical standard of care for that disease or condition.
For Members who are receiving services that are the subject of an Internal Review or Appeal, those services will be continued until the Internal Review or Appeal is resolved. However, if Molina prevails on final determination of the Internal Review or Appeal, the member may be responsible for the cost of the coverage received during the review period.
After the Internal Review or Appeal is complete, Molina will send the Member a written decision no more than two (2) business days after the review has been completed, and will provide information about what information was considered, including the clinical basis for the determination and how the Member can obtain the clinical review criteria used to help make the decision. If applicable, Molina will also provide the Member with information for obtaining an External Review or Appeal of a Final Internal Adverse Benefit Determination. Molina's decision, and any documents related to the decision, will be provided to the Member at the address Molina has on record for the Member, or with the Member's written consent, such records may be sent electronically.
Members may request an expedited Internal Review or Appeal of an Adverse Benefit Determination if one of the following conditions applies:
Requests for expedited Internal Review or Appeal may be made in writing or by telephone. The Member, a person designated by the Member to assist, or the Member's Provider may contact Molina by telephone or in writing at the phone number or address shown in the Reference Guide on page 2 of this Agreement.
If the Member's Provider determines that a delay could jeopardize the Member's health or ability to regain maximum function, Molina will presume the need for an expedited review and treat the review as such, including the need for an expedited determination of an external review.
Members may submit information, comments, records, and other items to assist in the review. Members may review and copy Molina's records and information relevant to the claim free of charge. Molina will consider all information submitted prior to making a determination. This review will be conducted by an appropriate clinical peer or peers in the same or similar specialty as would typically manage the case being reviewed. The clinical peer or peers will be individuals who were not involved in making the initial Adverse Benefit Determination.
If Molina requires additional information to determine whether the service or treatment decision being reviewed is covered under this Agreement, or eligible for benefits, Molina will request such information as soon as possible after receiving the request for expedited review.
Molina will notify the Member of the decision regarding an expedited Internal Review no later than 72 hours after the initial contact. If the decision was delivered orally, Molina's decision will be issued in writing not later than 72 hours after the date of the decision.
Members may also request a concurrent expedited review of an Adverse Benefit Determination, which means that the Internal Review or Appeal and the External Review or Appeal are handled at the same time. Concurrent expedited reviews are available if one of the following conditions applies:
Requests for concurrent expedited review may be made in writing or by telephone. The Member, a person designated by the Member to assist, or the Member's Provider may contact Molina Customer Support by telephone or in writing at the phone number or address shown in the Reference Guide on page 2 of this Agreement.
Molina will issue a formal response no later than 72 hours after receipt of the request. Please see below for more information on External Review or Appeals.
Within 180 days after the Member has received Molina's Final Internal Adverse Benefit Determination, or if Molina has not responded to a request for an Internal Review or Appeal within the time periods noted above, the Member may request an External Review or Appeal from an Independent Review Organization ("IRO"). Molina may require the Member to exhaust Molina's review process, prior to requesting an external review. If Molina does waive this requirement, and Molina then reverses the final Adverse Determination, Molina will immediately notify the member and the IRO. Requests for External Review or Appeals must be in writing and sent to Molina Customer Support at the mailing address or electronic mail address shown in the Reference Guide on page 2 of this Agreement.
Upon receipt of a valid request for an External Review or Appeal, Molina will arrange for the review from an IRO, selected on a rotating basis, at no cost to the Member, and will provide the Member with the IRO contact information within 24 hours of selecting the IRO. The IRO is unbiased and not controlled by Molina. Molina will provide the IRO with the appeal documentation, but the Member may also provide them with information.
The IRO process is optional and the Member pays no application or processing fees of any kind. The Member has the right to give information in support of their request and has 5 business days from the request for an External Review or Appeal to submit any supporting written information to the IRO. If the member is receiving services that are the subject of the Appeal, those services will be continued until the matter is resolved by the IRO. If Molina's Adverse Benefit Determination is upheld by the IRO, the member may be responsible for paying for any services that have been continued during the External Review or Appeal.
The dispute will be submitted to the IRO's medical reviewers who will make an independent determination of whether or not the care is Medically Necessary or appropriate and the application of this Policy's coverage provisions to the Member's health care services. All documents submitted to the IRO will also be made available to the Member. This includes all relevant clinical review criteria, all relevant evidence, Provider's recommendations and a copy of this Agreement. The Member will get a copy of the IRO's Final External Review Decision. If the IRO determines the service is Medically Necessary or appropriate for coverage under the Policy, Molina will provide the health care service.
If the Member's case involves Experimental or Investigational treatment, the IRO will ensure that adequate clinical and scientific experience and protocols are taken into account.
For non-urgent cases, the IRO must provide its determination within the earlier of fifteen (15) days after the IRO receives the necessary information or twenty (20) days of receipt of their request.
Members may request an expedited External Review or Appeal if one of the following conditions apply:
If the External Review or Appeal is expedited, the IRO must notify the Member within 72 hours of its Final External Review Decision. If the notice is not in writing, the IRO must provide the Member with written confirmation of its Final External Review Decision within 48 hours after the date of the decision.
For more information regarding the External Review or Appeal process, or to request an appeal, please call Molina Customer Support at the number shown in the Reference Guide on page 2 of this Agreement.
Washington State Office of the Insurance Commissioner
Members who have any questions or grievances regarding Molina's handling of a grievance or appeal, may contact the Washington State Office of the Insurance Commissioner. A Washington State Office of the Insurance Commissioner representative will review the issues, and if the representative can't help the Member, he or she will point the Member in the right direction for further assistance.
The Washington State Office of the Insurance Commissioner's Consumer Protection Division is currently designated by the U.S. Department of Health and Human Services as the official ombudsman in the State of Washington for consumers who have questions or complaints about health care appeals:
Washington State Office of the Insurance Commissioner
Call 1 (800) 562-6900 or Call 1 (360) 725- 7080
TDD 1 (360) 586- 241
Fax to 1 (360) 586-2018