Complaints and Appeals

Member Complaint (Grievance) 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.

GRIEVANCES AND APPEALS

Definitions Used in Grievances and Appeals

“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 or Appeal” means a request by a Member or the Member’s designated representative for an Independent Review Organization to determine whether Molina Healthcare’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 or Appeal.

“Final Internal Adverse Benefit Determination” means an Adverse Benefit Determination that has been upheld by Molina Healthcare 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” 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 Healthcare.

“Independent Review Organization” means a certified independent review organization established by the Washington State Insurance Commissioner that is not affiliated with Molina Healthcare.“Internal Review of Adverse Benefit Determination” means the request by or on behalf of a Member to review and reconsider an Adverse Benefit Determination.

What if I Have a Complaint (Grievance)?

If You have a problem with any Molina Healthcare services, we want to help.

Molina Healthcare recognizes the fact that Members 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 problems and complaints. You may file a Grievance (also called a complaint) in person, in writing, or by telephone. You must file Your Grievance within one hundred eighty (180) days from the day the incident or action occurred which caused You to be unhappy.We will never retaliate against a Member in any way for filing a Grievance.

You or a person designated by You to assist can contact us by telephone or in writing at:

• Call Molina Healthcare toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 6:00 p.m. PT. Deaf or hard of hearing Members may dial 711 for the Telecommunication Service. If You need assistance to file a Grievance in a language other than English or need an accessible format, our Customer Support Center can make arrangements for translation or interpreter assistance.
• You may also send us Your Grievance in writing by mail or by filing online at our website. Our address is:

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
MolinaMarketplace.com

We will send You a letter acknowledging receipt of Your Grievance within 72 hours of our receipt of the request. Grievances will be resolved within thirty (30) calendar days.

If you prefer to receive your appeal and/or grievance documents electronically, please download the Consent Form and return the signed original to us at the address shown on the form.

Review of Adverse Benefit Determination

When You receive an Adverse Benefit Determination, You can file a request for an internal review of the Adverse Benefit Determination with Molina. We will process Your written or oral request for an internal review of an Adverse Benefit Determination, also called an Appeal. We will never retaliate against a Member in any way for filing a Grievance.There are two levels of appeals, an Internal Review and an External Review. When the Internal Review is final, You may request an External Review of the Final Internal Adverse Benefit Determination as explained below.

Internal Review of Adverse Benefit Determination

Requests for Internal Review or Appeal of Adverse Benefit Determinations must be received within 180 days of Your receipt of an Adverse Benefit Determination. Requests for Internal Review or Appeals may be made by calling Molina Healthcare at 888-858-3492 between 8:00 a.m. to 6:00 p.m. PT Monday through Friday, or in writing and sent to the following mailing address or electronic mail address:

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
MolinaMarketplace.com

We will send You a letter acknowledging receipt of Your request for Internal Review or Appeal within 72 hours of our 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 (20) working 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 we notify You of the extension and the reason for the extension. Any further extensions by us are subject to Your informed written consent to an extension. An extension will not extend the time for a determination beyond twenty (20) calendar days without Your written consent.

You may submit information, comments, records and other items to assist in the review. You may review and copy our records and information relevant to the claim free of charge. We will consider all information submitted prior to making our determination. Our review panel 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 Your condition or disease and make a determination that is within the clinical standard of care for Your disease or condition.

If You 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 if You request the continuation. However, if Molina prevails on final determination of the Internal Review or Appeal, You may be responsible for the cost of the coverage received during the review period.

After the Internal Review or Appeal is complete, We will send You a written decision on Your appeal determination, no more than two (2) business days after the review has been completed, and will provide information about what we considered,including the clinical basis for our determination and how You can obtain the clinical review criteria used to help make the decision. If applicable, we will also provide You with information for obtaining an External Review or Appeal of a Final Internal Adverse Benefit Determination.Our decision, and any documents related to the decision, will be provided to you at the address We have on record for You, or with Your written consent such records may be sent electronically.

Expedited Review of Adverse Benefit Determination

You may request an expedited Internal Review or Appeal of an Adverse Benefit Determination if one of the following conditions applies:

• You are currently receiving or have been prescribed treatment or benefits that would end because of the Adverse Determination; or
• If Your provider believes that a delay in treatment based on the standard review time may seriously jeopardize Your life, overall health, or ability to regain maximum function, or would subject You to severe and intolerable pain; or
• If the Adverse Determination is related to an admission, availability of care, continued stay, or emergency health care services and You have not been discharged from the emergency room or transport service.

Requests for expedited Internal Reviews or Appeals may be made in writing or by telephone.

You, a person designated by You to assist, or Your provider may contact us by telephone or in writing at:

If Your Provider determines that a delay could jeopardize Your 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.

• Call Molina Healthcare toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 6:00 p.m. PT. Deaf or hard of hearing Members may dial 711 for the Telecommunication Service.
• Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
MolinaMarketplace.com


You may submit information, comments, records, and other items to assist in the review. You may review and copy Our records and information relevant to the claim free of charge. We will consider all information submitted prior to making Our 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.We will notify You of Our decision to an expedited Internal Review no later than 72 hours after Your initial contact with Us. If Our decision was delivered orally, Our decision will be issued in writing not later than 72 hours after the date of the decision.

You 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:

• You are currently receiving or have been prescribed treatment or benefits that would end because of the Adverse Determination.
• If Your provider believes that a delay in treatment based on the standard review time may seriously jeopardize Your life, overall health, or ability to regain maximum function, or would subject You to severe and intolerable pain.
• If the Adverse Determination is related to an admission, availability of care, continued stay, or emergency health care services and You have not been discharged from the emergency room or transport service.

Requests for concurrent expedited review may be made in writing or by telephone. You, a person designated by You to assist, or Your provider may contact us by telephone or in writing at:

• Call Molina toll-free at 1 (888) 858-3492, Monday through Friday, 8:00 a.m. - 6:00 p.m. PT.
• Deaf or hard of hearing Members may dial 711 for the Telecommunication Service.

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
MolinaMarketplace.com


Molina Healthcare will issue a formal response no later than 72 hours after Your initial contact with us. Please see below for more information on External Review or Appeals.

External Review of Adverse Benefit Determination

Within 180 days after You have received our Final Internal Adverse Benefit Determination, or if we have not responded to Your request for an Internal Review or Appeal within the time periods noted above, You may request an External Review or Appeal from an Independent Review Organization (“IRO”). Requests for External Review or Appeals must be in writing and sent to the following mailing address or electronic mail address:

Molina Healthcare
Grievance and Appeals Unit
P.O. Box 4004
Bothell, WA 98041
MolinaMarketplace.com


Upon receipt of a valid request for an External Review or Appeal, Molina will arrange for the review from an Independent Review Organization (IRO) at no cost to You, and will provide You with the IRO contact information within 24 hours of selecting the IRO. The IRO is unbiased and not controlled by Us. We will provide the IRO with the appeal documentation, but You may also provide them with information.

The IRO process is optional and You pay no application or processing fees of any kind. You have the right to give information in support of Your request and have 5 business days from the request for an External Review or Appeal to submit any supporting written information to the IRO. If You are receiving services that are the subject of the appeal, those services will be continued until the matter is resolved by the IRO if You request the continuation. If our Adverse Benefit Determination is upheld by the IRO, You 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 Your health care services. All documents submitted to the IRO will also be made available to You. This includes all relevant clinical review criteria, all relevant evidence, providers recommendations and copy of this Agreement. You 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 Your 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 Your request.

You may request an expedited External Review or Appeal if one of the following conditions apply:

• You receive a Final Adverse Benefit Determination concerning an admission, availability of care, continued stay, or health care service for which You received emergency services and have not been discharged from the facility.
• You receive a Final Adverse Benefit Determination involving a medical condition for which the standard external review time would seriously jeopardize Your life or health or jeopardize Your ability to regain maximum function.
• Your request for a concurrent expedited review is granted.



If the External Review or Appeal is expedited, the IRO must notify You within 72 hours of its Final External Review Decision. If the notice is not in writing, the IRO must provide You 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 Healthcare toll-free at 1 (888) 858-3492. If You are deaf or hard of hearing, dial 711 for the Telecommunication Service.

Washington State Office of the Insurance Commissioner

If You have any questions or grievances regarding our handling of Your Grievance or appeal, You may contact the Washington State Office of the Insurance Commissioner. A Washington State Office of the Insurance Commissioner representative will review your issues, and if the representative can’t help you, he or she will point you 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) 586-0241
Fax to 1 (360) 586-2018
Email CAP@oic.wa.gov


The OIC complaint form can be accessed at: https://www.insurance.wa.gov/file¬complaint-or-check-your-complaint-status.com