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 any of the following toll-free numbers for help:

• Call Molina Healthcare toll-free at 1 (888) 560-5716, Monday through Friday, 8:00 a.m. - 6:00 p.m. ET.
• Deaf or hard of hearing Members may call Our toll-free TTY number at 1 (800) 955-8771. You may also contact us by calling the National Relay Service at 711.
• You may also send us Your problem or complaint in writing by mail or filing online at Our website. Our address is:

Molina Healthcare of Florida, Inc.

Attention: Complaints and Appeals Coordinator

PO Box 521838

Miami, Florida 33152-1838

Fax: 1 (877) 508-5748

www.molinahealthcare.com

• You can also contact the Florida Department of Financial Services at:

Department of Financial Services

Division of Consumer Services

200 E. Gaines Street

Tallahassee, FL 32399-0322

Toll-free: 1-877-693-5236

TDD: 1-800-640-0886

 

Member Grievance/Appeal Request Form

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, are not Adverse Benefit Determinations.

“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.

“DFS”: means the Florida Department of Financial Services.

“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

You 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 Florida, Inc.
Attention: Complaints and Appeals Coordinator
PO Box 521838
Miami, Florida 33152-1838
1-888-560-5716
1-800-955-8771 TTY
Fax: 1-877-508-5748
www.molinahealthcare.com

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

You or Your Authorized Representative 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. It will include input from 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 processes 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.

External Appeal

After You have exhausted the 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 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 123 calendar days 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 1888-866-6190, online at www.externalappeal.cms.gov 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 1-888-866-6205. 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 appeal of an Urgent Care Service would seriously jeopardize Your life or health or would jeopardize Your ability to regain maximum function and You have filed a request for a review of an Urgent Care Service; 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 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.

Department of Financial Services
Division of Consumer Services
200 E. Gaines Street
Tallahassee, FL 32399-0322
Toll-free: 1-877-693-5236
TDD: 1-800-640-0886

Molina Healthcare of Florida, Inc.
Attn: Complaints and Appeals Coordinator
PO Box 521838
Miami, Florida 33152-1838
1-888-560-5716
1-800-955-8771 TTY
Fax: 1-877-508-5748
www.molinahealthcare.com