GRIEVANCES (INTERNAL APPEALS) AND EXTERNAL APPEALS
Definitions for this “Grievance (Internal Appeals) and External Appeals” section
"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;
- 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 Participating Providers, where You are not liable for such services or charges, are not Adverse Benefit Determinations.
"Authorized Representative" means an individual authorized by You, in accordance with the provisions of this "Grievances (Internal Appeals) and External Appeals" section, to act on Your behalf with respect to a Grievance or external appeal.
"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, then the internal appeal will be deemed to be a Final Adverse Benefit Determination.
"Grievance" means any dissatisfaction with Molina that is expressed in writing to Molina by You, or Your Authorized Representative, including, but not limited to, any of the following:
- Adverse Benefit Determination
- Provision of Covered Services;
- Determination to reform this Agreement;
- Determination of a diagnosis or level of service required for evidence-based treatment of autism spectrum disorders; or
- Claims practices.
"Grievance Panel" means a group of people responsible for the investigation of each Grievance.
"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.
"Expedited Grievance": means a Grievance where the standard resolution process may include any of the following:
- Serious jeopardy to Your life or health (or the life or health of Your unborn child) or Your ability to regain maximum function; 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 Grievance; or
- Is determined to be an expedited Grievance by the treating physician.
- You or Your Authorized Representative may submit the signed Grievance form and any supporting materials to the Grievance Panel using one of the following methods:
Molina Healthcare of Wisconsin, Inc.
Attn: Grievance Coordinator
11002 W. Park Place,
Milwaukee, WI 53224
Molina will acknowledge receipt of the Grievance in writing within five business days of receiving it. If Your Authorized Representative filed the Grievance on Your behalf, We will also provide a notice that health care information or medical records may be disclosed only if permitted by law. We will also include an informed consent form.
- Molina will notify You and Your Authorized Representative (if applicable) in writing of the time and place of the Grievance Panel meeting at least seven calendar days in advance. You or Your Authorized Representative have the right to appear before the Grievance Panel in person or by telephone to present written or oral information concerning the Grievance. You may also submit written questions to the persons responsible for making the determination that resulted in the denial or determination of benefits or a decision to disenroll You.
- Except if Your Grievance is an Expedited Grievance as described in paragraph 4 below, Molina will notify You of the disposition of the Grievance within 30 calendar days of receipt, unless Molina is not able to resolve the Grievance within 30 calendar days. In the event Molina is unable to make a determination within the initial 30 calendar days of receipt of Your Grievance, Molina may extend the determination period for an additional 30 calendar days. If an extension is required, We will notify You in writing:
- That Molina has not resolved the Grievance;
- Of the reasons for the extension; and
- When resolution may be expected.
- If a Grievance involves an Expedited Grievance, Molina will resolve such Grievance within 72 hours after receipt. You may request an Expedited Grievance by calling us at
1-888-560-2043. If You are deaf or hard of hearing, You may contact us by dialing
7-1-1 for the National Relay Service. You may fax your request to:
- You may review Molina’s claim file without charge, including any new or additional evidence or rationale considered, relied upon or generated by Molina in connection with the claim.
- Molina will require a written expression of authorization for representation from any person acting on Your behalf unless any of the following applies:
- The person acting on Your behalf is authorized by law to act on Your behalf;
- You are unable to give consent and the person acting on Your behalf is a spouse, family member or the treating provider; or
- The Grievance is an Expedited Grievance and the person acting on Your behalf represents that You have verbally given him/her authorization to represent You.
Molina shall process a Grievance without requiring written authorization unless We, in Our acknowledgement of receipt of a Grievance to the Authorized Representative, clearly and prominently do all of the following:
- Notify the person acting on Your behalf that, unless any of the exceptions listed above apply, the Grievance will not be processed until We receive a written authorization.
- Request written authorization from the person acting on Your behalf.
- Provide the person acting on Your behalf a form You may use to give written authorization. You may, but are not required to, use Our form to give written authorization. Molina will accept a written expression of authorization in any form, language or format.
Filing an External Appeal
After You have exhausted the Grievance (internal appeal) rights provided by Molina, You have the right to request an external/independent review of an Adverse Benefit Determination. You (or Your Authorized Representative) may file a written request for an external review. Your notice of Adverse Benefit Determination and/or Final Adverse Benefit Determination describes the process to follow if You wish to pursue an external appeal.
You must submit Your request for external review within four months of the date You receive the notice of Adverse Benefit Determination or Final Adverse Benefit Determination.
You can request an external appeal by fax at 1-888-866-6190, online at www.externalappeal.com, or by mail at:
HHS Federal External Review Request
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.
If You have any questions or concerns during the external appeal process, You (or Your Authorized Representative) can call the toll-free number
. You (or Your Authorized Representative) can submit additional written comments to the external reviewer at the mailing address above. If any additional information is submitted, it will be shared with Molina in order to give us an opportunity to reconsider the denial.
Request for expedited external appeal – You (or Your Authorized Representative) may make a written or oral request for an expedited external appeal with the external reviewer when You receive:
- An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an Expedited Grievance would seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function and You have filed a request for an Expedited Grievance; or
- A Final Adverse Benefit Determination, if You have a medical condition where the timeframe for completion of a standard external review would seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function, or if the final internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received services, but has not been discharged from a facility.
- An Adverse Benefit Determination that relates to Experimental or Investigational treatment, if the treating physician certified that the recommended or requested health care service, supply, or treatment would be significantly less effective if not promptly initiated.
In expedited external appeal situations, requests for expedited review can be initiated by calling MAXIMUS Federal Services toll free at 1-888-866-6205, or by faxing the request to 1-888-866-6190, or by mailing the request to:
HHS Federal External Review Request
MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534.
Additionally, at Your request, Molina can send You copies of the actual benefit provision, and will provide a copy at no charge, of the actual benefit, clinical guidelines or clinical criteria used to make the determination upon receipt of Your request. A request can be made by calling the Molina Complaints and Appeals Coordinator.
General Rules and Information
General rules regarding Molina's Complaints, Grievances (Internal Appeals) and External Appeals Process include the following:
- Molina will offer to speak 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 directly to You so You have an opportunity to review the claim file.