State Fair Hearing/External Medical Reviews
Members have the right to ask for a State Fair Hearing if they disagree with a decision made by Molina Healthcare. A State Fair Hearing can be requested after you complete Molina Healthcare's appeal process. A State Fair Hearing must be requested within 120 days from the date on the Appeal Resolution letter from Molina Healthcare. If a State Fair Hearing is not requested within 120 days, rights to a State Fair Hearing may be lost.
Members who requested and received continued services during the appeal process have the right to continue any service being received until the final hearing decision. To continue receiving services during the State Fair Hearing, the Member must request the State Fair Hearing within ten (10) business days of the date on the Appeal Resolution letter from Molina Healthcare. If a State Fair Hearing is not filed within ten (10) business days, the services being appealed will be discontinued.
If a State Fair Hearing is requested, a packet of information with the date, time and location of the Hearing will be sent to the member. Members may write or call toll-free at any time during the appeals process (866) 449-6849.
Most State Fair Hearings are held by telephone and the member or member representative will be able to discuss the services being appealed.
Members can bring someone who knows about the case to attend the hearing. Members may also bring someone else to represent them. This person can be a doctor, a friend or a relative.
The Texas Health and Human Services Commission will make a final decision within 90 days from the date that the Hearing was requested.
If you ask for a State Fair Hearing, you can also ask for an External Medical Review where independent healthcare experts review your request to continue receiving services. If you ask for an External Medical Review, it will happen before your State Fair Hearing. An External Medical Review doesn’t affect when your state fair hearing will be scheduled. The External Medical Review must be requested within 120 days from the date on the internal appeal decision letter from Molina Healthcare. If you do not ask for an External Medical Review within 120 days, you may lose your right to an External Medical Review.
This review is an optional, extra step you can take to get your case reviewed for free before your State Fair Hearing. It doesn't change your right to a State Fair Hearing.
About the External Medical Review
- HHSC will give your information to independent healthcare experts who will review your case.
- Only the information submitted for your health plan appeal will be used. You won't be able to give new information for the review.
- The experts can agree with or change our decision. Their external medical review decision will be mailed to you in ten (10) calendar days or less.
- After you get your external medical review decision, you can choose if you want to also have the State Fair Hearing you requested.
- If you want to have your State Fair Hearing, the External Medical Review decision may be considered as evidence during your State Fair Hearing.
To request, receive or get a status update on a State Fair Hearing and External Medical Review, you or your assigned representative can contact Molina Healthcare in writing or by telephone at:
Molina Healthcare of Texas
PO Box 165089
Irving, Texas 75016
Attention: Appeals and Grievances Department
Phone: (866) 449-6489
TTY: (800) 662-4954
Emailing us at: TXMemberInquiryResearchAndResolution@MolinaHealthCare.Com