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| Molina Medicare
- How to file grievances and appeals |
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We encourage you to let us know right away if you have
questions, concerns, or problems
related to your covered services or the care you
receive. Please call Member Services at 1-800-665-0898 Monday-Sunday 8:00 am - 8:00 pm, TTY/TDD users can call 1-800-346-4128. (Hours of Operation:
Monday through Sunday 8:00 a.m. to 8:00 p.m.) |
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| Note that sections
10
and
11
of the EOC* do not apply to Part D prescription
drug benefits. See
section12 of the EOC* for
detailed information about how to make an appeal that
involves a request for Part D drug
benefits. [*EOC: Links in this section go to the 2007 Evidence of Coverage. 2008 Evidence of Coverage is coming soon] |
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| This section gives the rules for making complaints in
different types of situations. Federal law
guarantees your right to make complaints if you have
concerns or problems with any part of your
medical care as a plan member. The Medicare program has
helped set the rules about what you
need to do to make a complaint and what we are required
to do when we receive a complaint. If
you make a complaint, we must be fair in how we handle
it. You cannot be disenrolled from
Molina Medicare or penalized in any way if you make a
complaint. |
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| What are appeals and grievances? |
You have the right to make a complaint if you have
concerns or problems related to your
coverage or care. "Appeals" and "grievances" are the two
different types of complaints you can
make. |
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An "appeal" is the type
of complaint you make when you want us to reconsider
and change a
decision we have made about what services or benefits
are covered for you or what we will
pay for a service or benefit. For example, if we refuse
to cover or pay for services you think
we should cover, you can file an appeal. If Molina
Healthcare of California or one of our
plan providers refuses to give you a service you think
should be covered, you can file an
appeal. If Molina Healthcare of California or one of our
plan providers reduces or cuts back
on services or benefits you have been receiving, you can
file an appeal. If you think we are
stopping your coverage of a service or benefit too soon,
you can file an appeal. |
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A "grievance" is the
type of complaint you make if you have any other
type of problem
with Molina Healthcare of California / Molina Medicare
or one of our plan providers. For
example, you would file a grievance if you have a
problem with things such as the quality of
your care, waiting times for appointments or in the
waiting room, the way your doctors or
others behave, being able to reach someone by phone or
get the information you need, or the
cleanliness or condition of the doctor's office. |
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| To obtain information on the number of grievances, appeals, and exceptions filed with Molina Options Plus please call 1-800-665-0898 Monday-Sunday 8:00 am - 8:00 pm, TTY/TDD users can call 1-800-346-4128. (Hours of Operation:
Monday through Sunday 8:00 a.m. to 8:00 p.m.) |
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| This section tells how to make complaints in different
situations |
The rest of this section has separate parts that tell
you how to make a complaint in each of the
following situations: |
| 1. |
Complaints about what
we will cover for you or what we will pay for. If
Molina
Healthcare of California or your doctor or another plan
provider has refused to give you a
service you think is covered, you can make a complaint
called an appeal. If we have
refused to pay for a service you think is covered for
you, you can make an appeal. If you
have been receiving a covered service, and you think
that service is being reduced or
ending too soon, you can make an appeal. When you file
an appeal, you are asking us to
reconsider and change a decision we have made about what
services we will cover for
you (which includes whether we will pay for your care or
how much we will pay). |
| 2. |
Complaints about your
Part D prescription drug benefits that we will cover
or pay
for. If Molina Healthcare of California refused to give
you a Part D prescription drug
benefit that you think is covered, you can request an
appeal. If we have refused to pay
for a Part D prescription drug that you have already
received and you believe that it is
covered, you can make an appeal. If you have been
receiving a Part D prescription drug,
and you think its coverage is being reduced or ending
too soon, you can make an appeal.
When you file an appeal, you are asking us to reconsider
and change a decision we have
made about what Part D prescription drug we will cover
for you (which includes whether
we will pay for a Part D prescription drug that you have
already received, or how much
we will pay). The rules that apply to appeals of drug
coverage are different than the rules
that apply to your health benefits. Be sure to read
Section 12 so that you clearly
understand the difference. |
| 3. |
Complaints if you think
you are being discharged from the hospital too soon.
There
is a special type of appeal that applies only to
hospital discharges. If you think our
coverage of your hospital stay is ending too soon, you
can appeal directly and
immediately to Lumetra, which is the Quality Improvement
Organization in the state of
California.. Lumetra is a group of health professionals
in California that is paid to handle
this type of appeal from Medicare patients. If you make
this type of appeal, your stay
may be covered during the time period the QIO uses to
make its determination. You must
act very quickly to make this type of appeal, and it
will be decided quickly. |
| 4. |
Complaints if you think
your coverage for Skilled Nursing Facility (SNF), Home
Health (HHA) or Comprehensive Outpatient Rehabilitation
Facility (CORF)
services is ending too soon. There is another special
type of appeal that applies only
when coverage will end for SNF, HHA or CORF services. If
you think your coverage is
ending too soon, you can appeal directly and immediately
to Lumetra, which is the
Quality Improvement Organization in the state of
California. If you make this type of
appeal, your stay may be covered during the time period
the QIO uses to make its
determination. You must act very quickly to make this
type of appeal, and it will be
decided quickly. |
| 5. |
Complaints about any
other type of problem you have with Molina
Healthcare of
California / Molina Medicare or one of our plan
providers. If you want to make a
complaint about any type of problem other than those
that are listed above, a grievance is
the type of complaint you would make. For example, you
would file a grievance to
complain about problems with the quality or timeliness
of your care, waiting times for
appointments or in the waiting room, the way your
doctors or others behave, being able
to reach someone by phone or get the information you
need, or the cleanliness or
condition of the doctor's office. Generally, you would
file the grievance with Molina
Healthcare of California. But for many problems related
to quality of care you get from
plan providers, you can also complain to the QIO in your
state. |
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| Part 1. Complaints (appeals) to Molina Healthcare of
California to
change a decision about what services we will cover or
what
we will pay for |
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| This part explains what you can do if you
have problems getting the medical care
you believe we should provide. We use the word "provide"
in a general way to include such
things as authorizing care, paying for care, arranging
for someone to provide care, or continuing
to provide a medical treatment you have been getting.
Problems getting the medical care you
believe we should provide include the following
situations: |
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If you are not getting
the care you want, and you believe that this care is
covered by
Molina Medicare. |
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If we will not
authorize the medical treatment your doctor or other
medical provider
wants to give you, and you believe that this treatment
is covered by Molina Medicare. |
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If you are being told
that coverage for a treatment or service you have
been getting will
be reduced or stopped, and you feel that this could harm
your health. |
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If you have received
care that you believe was covered by Molina Medicare while you
were a member, but we have refused to pay for this care. |
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| Six possible steps for requesting care or payment from
Molina Medicare: |
| If you are having a problem getting care or payment for
care, there are six possible steps you can
take to ask for the care or payment you want from us. At
each step, your request is considered
and a decision is made. If you are unhappy with the
decision, you may be able to take another
step if you want to continue requesting the care or
payment. |
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In Steps 1 and 2, you
make your request directly to us. We review it and
give you our
decision. |
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In Steps 3 through 6,
people in organizations that are not connected to us
make the
decisions about your request. To keep the review
independent and impartial, those who
review the request and make the decision in Steps 3
through 6 are part of (or in some
way connected to) the Medicare program or the federal
court system. |
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| The six possible steps are summarized below (they are
covered in more detail in
Section 11
of the EOC*). |
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| Step 1: The initial decision by Molina Healthcare of
California |
| The starting point is when we make an "initial decision"
(also called an "organization
determination") about your medical care or about paying
for care you have already received.
When we make an "initial decision," we are giving our
interpretation of how the benefits and
services that are covered for members of Molina Medicare apply to your specific situation. As
explained in
Section 11
of the EOC*, you can ask for a "fast initial
decision" if you have a request for medical
care that needs to be decided more quickly than the
standard time frame. |
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| Step 2: Appealing the initial decision by Molina
Healthcare of California |
| If you disagree with the decision we make in Step 1, you
may ask us to reconsider our decision.
This is called an "appeal" or a "request for
reconsideration." As explained in
Section 11
of the EOC*, you
can ask for a "fast appeal" if your request is for
medical care and it needs to be decided more
quickly than the standard time frame. After reviewing
your appeal, we will decide whether to
stay with our original decision, or change this decision
and give you some or all of the care or
payment you want. |
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| Step 3: Review of your request by an Independent Review
Organization |
| If we turn down part or all of your request in Step 2,
we are required to send your request to an
independent review organization that has a contract with
the federal government and is not part
of Molina Healthcare of California. This organization
will review your request and make a
decision about whether we must give you the care or
payment you want. |
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| Step 4: Review by an Administrative Law Judge |
If you are unhappy with the
decision made by the independent review
organization that reviews your case in Step 3, you
may ask for an Administrative Law Judge to
consider your case and make a decision. The
Administrative Law Judge works for the federal
government. The dollar value of your contested
benefit must be at least $110.00 to be considered
in Step 4. |
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| Step 5: Review by a Medicare Appeals Council |
| If you or we are unhappy with the decision made in Step
4, either of us may be able to ask a
Medicare Appeals Council to review your case. This
Council is part of the federal department
that runs the Medicare program. |
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| Step 6: Federal Court |
| If you or
we are unhappy with the decision made by the Medicare
Appeals Council in Step 5,
either of us may be able to take your case to a Federal
Court. The dollar value of your contested
medical care must at least $1090.00 to go to a Federal
Court. |
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| For a more detailed explanation of all six steps
outlined above, see
Section 11
of the EOC*. |
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| Part 2. Complaints (appeals) to Molina Healthcare of
California to
change a decision about what Part D drugs we will cover
or
pay for |
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| This part of Section 10 explains what you can do if you
have problems getting the prescription
drugs you believe we should provide. We use the word
"provide" in a general way to include
such things as authorizing prescription drugs, paying
for prescription drugs, or continuing to
provide a Part D prescription drug that you have been
getting. Problems getting a Part D
prescription drug that you believe we should provide
include the following situations: |
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If you are not able to
get a prescription drug that you believe may be
covered by Molina Medicare. |
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If you have received a
Part D prescription drug you believe may be covered
by Molina Medicare while you were a member, but we have refused
to pay for the drug. |
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If we will not provide
or pay for a Part D prescription drug that your
doctor has
prescribed for you because it is not on our formulary. |
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If you disagree with
the amount that we require you to pay for a Part D
prescription drug
that your doctor has prescribed for you. |
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If you are being told
that coverage for a Part D prescription drug that
you have been
getting will be reduced or stopped. |
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If there is a
requirement that you try another drug before we pay
for the drug your doctor
prescribed, or if there is a limit on the quantity (or
dose) of the drug and you disagree
with the requirement or dosage limitation. |
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| Six possible steps for requesting a Part D benefit or
payment from Molina Medicare |
| If you are having a problem getting a Part D benefit or
payment for a Part D prescription drug
that you have already received, there are six possible
steps you can take to ask for the benefit or
payment you want from us. At each step, your request is
considered and a decision is made. If
you are unhappy with the decision, you may be able to
take another step if you want to continue
requesting the benefit or payment. |
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In Steps 1 and 2, you
make your request directly to us. We review it and
give you our
decision. |
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In Steps 3 through 6,
people in organizations that are not connected to us
make the
decisions about your request. To keep the review
independent and impartial, those who
review the request and make the decision in Steps 3
through 6 are part of (or in some
way connected to) the Medicare program or the federal
court system. |
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| The six possible steps are summarized below (they are
covered in more detail in
Section 12 of the EOC*). |
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| Step 1: The initial decision by Molina Healthcare of
California |
| The starting point is when we make an "initial decision"
(also called a "coverage determination")
about your Part D prescription drug or about paying for
Part D drug that you have already
received. When we make an "initial decision," we are
giving our interpretation of how the
benefits that are covered for members of Molina Medicare apply to your specific situation. As
explained in
Section 12 of the EOC*, you can ask for a "fast initial
decision" if you have a request for benefits
that needs to be decided more quickly than the standard
time frame. |
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| Step 2: Appealing the initial decision by Molina
Healthcare of California |
| If you disagree with the decision we make in Step 1, you
may ask us to reconsider our decision.
This is called an "appeal" or a "request for
redetermination." As explained in
Section 12 of the EOC*, you
can ask for a "fast appeal" if your request for benefits
needs to be decided more quickly than the
standard time frame. After reviewing your appeal, we
will decide whether to stay with our
original decision, or change this decision and give you
the benefit or payment you want. |
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| Step 3: Review of your request by an Independent Review
Organization |
| If we turn down your request in Step 2, you may ask an
independent review organization to
review our decision. The independent review organization
has a contract with the federal
government and is not part of Molina Healthcare of
California. The independent review
organization will review your request and make a
decision about whether we must give you the
benefit or payment you want. |
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| Step 4: Review by an Administrative Law Judge |
| If you are unhappy with the decision made by the
independent review organization that reviews
your case in Step 3, you may ask for an Administrative
Law Judge to consider your case and
make a decision. The Administrative Law Judge works for
the federal government. The dollar
value of your contested benefit must be at least $110.00
to be considered in Step 4. |
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| Step 5: Review by a Medicare Appeals Council |
| If you are unhappy with the decision made in Step 4, you
may be able to ask the Medicare
Appeals Council (MAC) to review your case. The MAC is
part of the federal department that
runs the Medicare program. |
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| Step 6: Federal Court |
| If you are unhappy with the decision made by the MAC in
Step 5, you may be able to take your
case to a Federal Court. The dollar value of your
contested benefit must be at least $1090.00 to
go to a Federal Court |
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| For a more detailed explanation of all six steps
outlined above, see
Section 12 of the EOC*. |
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| Part 3. Complaints (appeals) if you think you are being
discharged
from the hospital too soon |
When you are hospitalized, you have the right to get all
the hospital care covered by Molina Medicare that is necessary to diagnose and treat your
illness or injury. The day you leave the
hospital (your "discharge date") is based on when your
stay in the hospital is no longer medically
necessary. This part of
Section 10 of the EOC* explains what to do
if you believe that you are being
discharged too soon. |
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| Information you should receive during your hospital stay |
| When you are admitted to the hospital, someone at the
hospital should give you a notice called
the Important Message from Medicare. This notice
explains: |
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Your right to get all
medically necessary hospital services covered. |
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Your right to know
about any decisions that the hospital, your doctor,
or anyone else
makes about your hospital stay and who will pay for it. |
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That your doctor or the
hospital may arrange for services you will need
after you leave
the hospital. |
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Your right to appeal a
discharge decision. |
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| Review of your hospital discharge by the Quality
Improvement Organization |
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| If you
think that you are being discharged too soon, ask your
health plan to give you a notice
called the Notice of Discharge & Medicare Appeal Rights.
This notice will tell you: |
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Why you are being
discharged. |
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The date that we will
stop covering your hospital stay (stop paying our
share of your hospital
costs). |
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What you can do if you
think you are being discharged too soon. |
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Who to contact for
help. |
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| You (or someone you authorize) may be asked to sign and
date this document, to show that you
received the notice. Signing the notice does not mean
that you agree that you are ready to leave
the hospital - it only means that you received the
notice. If you do not get the notice after you
have said that you think you are being discharged too
soon, be sure to ask for it immediately. |
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| You have the right by law to ask for a review of your
discharge date. As explained in the Notice
of Discharge & Medicare Appeal Rights, if you act
quickly, you can ask an outside agency
called the Quality Improvement Organization to review
whether your discharge is medically
appropriate. |
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| What is the "Quality Improvement Organization"? |
| "QIO" stands for Quality Improvement Organization. The
QIO is a group of doctors and other
health care experts paid by the federal government to
check on and help improve the care given
to Medicare patients. They are not part of Molina
Healthcare of California or your hospital.
There is one QIO in each state. QIOs have different
names, depending on which state they are in.
In California, the QIO is called Lumetra. The doctors
and other health experts in Lumetra review
certain types of complaints made by Medicare patients.
These include complaints about quality
of care and complaints from Medicare patients who think
the coverage for their hospital stay is
ending too soon.
Section 1
of the EOC* tells how to contact the QIO. |
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| Getting a QIO review of your hospital discharge |
| If you want to have your discharge reviewed, you must
act quickly to contact the QIO. The
Notice of Discharge & Medicare Appeal Rights gives the
name and telephone number of your
QIO and tells you what you must do. |
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You must ask the QIO for a "fast review" of whether
you are ready to leave the hospital.
This "fast review" is also called a "fast appeal"
because you are appealing the discharge
date that has been set for you. |
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You must be sure that
you have made your request to the QIO no later than noon on the
first working day after you are given written notice
that you are being discharged from
the hospital. This deadline is very important. If you
meet this deadline, you are allowed
to stay in the hospital past your discharge date without
paying for it yourself, while you
wait to get the decision from the QIO (see below). |
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| If the QIO reviews your discharge, it will first look at
your medical information. Then it will
give an opinion about whether it is medically
appropriate for you to be discharged on the date
that has been set for you. The QIO will make this
decision within one full working day after it
has received your request and all of the medical
information it needs to make a decision. |
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If the QIO decides that your discharge date was
medically appropriate, you will not be
responsible for paying the hospital charges until noon
of the calendar day after the QIO
gives you its decision. |
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If the QIO agrees with you, then we will continue to
cover your hospital stay for as long
as medically necessary. |
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| What if you do not ask the QIO for a review by the
deadline? |
| You still have another option: asking Molina Healthcare
of California for a "fast appeal"
of your discharge |
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| If you do not ask the QIO for a "fast review" ("fast
appeal") of your discharge by the deadline,
you can ask us for a "fast appeal" of your discharge.
How to ask us for a fast appeal is covered
briefly in the first part of this section and in more
detail in
Section
11 of the EOC*. |
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| If you ask us for a fast appeal of your discharge and
you stay in the hospital past your discharge
date, you run the risk of having to pay for the hospital
care you receive past your discharge date.
Whether you have to pay or not depends on the decision
we make. |
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If we decide, based on
the fast appeal, that you need to stay in the
hospital, we will
continue to cover your hospital care for as long as
medically necessary. |
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If we decide that you
should not have stayed in the hospital beyond your
discharge date,
then we will not cover any hospital care you received if
you stayed in the hospital after
the discharge date. |
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| You may have to pay if you stay past your discharge date |
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| If you stay in the hospital after your discharge date
and do not ask for immediate QIO review,
you may be financially responsible for the cost of many
of the services you receive. However,
you can appeal any bills for hospital care you receive,
using Step 1 of the appeals process
described in
Section
11 of the EOC*. |
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| Part 4. Complaints (appeals) if you think your coverage
for SNF,
home health, or comprehensive outpatient rehabilitation
facility services are ending too soon. |
| When you are a patient in a SNF, Home Health Agency
(HHA), or Comprehensive Outpatient
Rehabilitation Facility (CORF), you have the right to
get all the SNF, HHA or CORF care
covered by Molina Medicare that is necessary to
diagnose and treat your illness or injury. The
day we end your SNF, HHA or CORF coverage is based on
when your stay is no longer
medically necessary. This part explains
what to do if you believe that your
coverage is ending too soon. |
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| Information you will receive during your SNF, HHA or
CORF stay |
| If we decide to end our coverage for your SNF, HHA, or
CORF services, you will get written
notice either from us or your provider at least 2
calendar days before your coverage ends. You
(or someone you authorize) will be asked to sign and
date this document to show that you
received the notice. Signing the notice does not mean
that you agree that coverage should end -
it only means that you received the notice. |
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| How to get a review of your coverage by the Quality
Improvement Organization |
| You have the right by law to ask for an appeal of our
termination of your coverage. As will be
explained in the notice you get from us or your
provider, you can ask the Quality Improvement
Organization (the "QIO") to do an independent review of
whether our terminating your coverage
is medically appropriate. |
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| How soon you have to ask the QIO to review your
coverage? |
| If you want to have the termination of your coverage
appealed, you must act quickly to contact
the QIO. The written notice you got from us or your
provider gives the name and telephone
number of your QIO and tells you what you must do. |
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If you get the notice 2
days before your coverage ends, you must be sure to
make your
request no later than noon of the day after you get the
notice. |
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If you get the notice
and you have more than 2 days before your coverage
ends, then you
must make your request no later than noon of the day
before the date that your Medicare
coverage ends. |
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| What will happen during the review? |
| If the QIO reviews your case, the QIO will ask for your
opinion about why you believe the
services should continue. You do not have to prepare
anything in writing, but you may do so if
you wish. The QIO will also look at your medical
information, talk to your doctor, and review
other information that we have given to the QIO. You and
the QIO will each get a copy of our
explanation about why your services should not continue. |
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| After reviewing all the information, the QIO will give
an opinion about whether it is medically
appropriate for your coverage to be terminated on the
date that has been set for you. The QIO
will make this decision within one full day after it
receives the information it needs to make a
decision. |
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| What happens if the QIO decides in your favor? |
| If the QIO agrees with you, then we will continue to
cover your SNF, HHA or CORF services
for as long as medically necessary. |
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| What happens if the QIO denies your request? If the QIO
decides that our decision to terminate
coverage was medically appropriate, you will be
responsible for paying the SNF, HHA or CORF
charges after the termination date on the advance notice
you got from us or your provider.
Neither Original Medicare nor Molina Healthcare of
California will pay for these services. If you
stop receiving services on or before the date given on
the notice, you can avoid any financial
liability. |
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| What if you do not ask the QIO for a review in time? |
| You still
have another option: asking Molina Healthcare of
California for a "fast appeal" of your
discharge. |
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| If you do not ask the QIO for a "fast appeal" of your
discharge by the deadline, you can ask us
for a "fast appeal" of your discharge. How to ask us for
a fast appeal is covered briefly in the
first part of this section and in more detail in
Section
11 of the EOC*. |
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| If you ask us for a fast appeal of your termination and
you continue getting services from the
SNF, HHA, or CORF, you run the risk of having to pay for
the care you receive past your
termination date. Whether you have to pay or not depends
on the decision we make. |
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If we decide, based on
the fast appeal, that you need to continue to get
your services
covered, then we will continue to cover your care for as
long as medically necessary. |
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If we decide that you
should not have continued getting coverage for your
care, then we
will not cover any care you received if you stayed after
the termination date. |
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| You may have to pay if you stay past your discharge
date. |
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| If you do not ask the QIO by noon after the day you are
given written notice that we will be
terminating coverage for your SNF, HHA or CORF services,
and if you stay in the SNF, HHA or
CORF after this date, you run the risk of having to pay
for the SNF, HHA or CORF care you
receive on and after this date. However, you can appeal
any bills for SNF, HHA or CORF care
you receive using Step 1 of the appeals process
described in
Section
11 of the EOC*. |
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| Part 5. Complaints (grievances) about any other type of
problem you
have with Molina Healthcare of California/Molina Medicare
or one of our plan providers |
| This last part of Section 10 explains how to make
complaints about any other type of
problem that has not already been discussed earlier in
this section. (The problems that have
already been discussed are problems related to coverage
or payment for care or Part D benefits,
problems about being discharged from the hospital too
soon, and problems about coverage for
SNF, HHA, or CORF services ending to soon.) |
|
| What is included in "all other types of problems"? |
| Here are some examples of problems that are included in
this category of "all other types of
problems": |
|
|
Problems with the
quality of the medical care you receive, including
quality of care
during a hospital stay. |
|
|
If you feel that you
are being encouraged to leave (disenroll from) Molina Medicare. |
|
|
Problems with the
Member Service you receive. |
|
|
Problems with how long
you have to spend waiting on the phone, in the
waiting room, or
in the exam room. |
|
|
Problems with getting
appointments when you need them, or having to wait a
long time
for an appointment. |
|
|
Disrespectful or rude
behavior by doctors, nurses, receptionists, or other
staff. |
|
|
Cleanliness or
condition of doctor's offices, clinics, or
hospitals. |
|
|
| If you have one of these types of problems and want to
make a complaint, it is called "filing a
grievance." In addition, you have the right to ask for a
"fast grievance" if you disagree with our
decision to not give you a "fast appeal" or if we take
an extension on our initial decision or
appeal. See below for more detail. |
|
| Filing a grievance with Molina Medicare |
| If you have a complaint, we encourage you to first call
Member Serivces at the number on the
cover of this booklet. We will try to resolve any
complaint that you might have over the phone.
If you request a written response to your phone
complaint, we will respond in writing to you. If
we cannot resolve your complaint over the phone, we have
a formal procedure to review your
complaints. We call this our Member Grievance Process. |
|
| You must file your grievance within 60 days of the event
that gives rise to the grievance. You
may file a grievance either orally or in writing, by one
of the methods below. Our business
hours are Monday - Sunday, 8:00 am - 8:00 pm. |
|
| CALL
1-800-665-0898. This number is also on the cover of
this booklet for easy
Calls to this number are free. |
|
| TTY
1-800-346-4128. This number requires special
telephone equipment. It is
on the cover of this booklet for easy reference. Calls
to this
number are
free. |
|
| FAX 1-866-771-0117 |
|
| WRITE |
Molina Medicare
ATTN: Grievance and Appeals Department
Union Park Center, Suite 300
Midvale, UT 84047 |
|
| We will respond to all written grievances in writing. We
will respond to oral grievances orally,
unless you specifically request a written response. We
will respond to all quality of care
grievances in writing, regardless of how the grievance
was filed. |
|
| Expedited Grievance Procedure: You (or your
representative, with appropriate authorization)
are entitled to an expedited grievance whenever Molina Medicare takes an extension relating to
an organization determination reconsideration, or when
we refuse to expedite a request for an
organization determination or reconsideration. Molina Medicare will respond to these
grievances with 24 hours after receipt. Our expedited
grievance determination will address only
your dissatisfaction with our decision to take an
extension or deny your request to expedite a
determination or appeal. The grievance determination
will not address the underlying issue
(request for services or payment, etc.) that is the
subject of the organization determination or
reconsideration. For after hours, weekend, or holiday
delivery please contact our Nurse Advice
Line which is available 24 hours a day 7 days a week at
1-888-275-8750 and 1-888-735-2955 for
TTY users. |
|
| Standard Grievance Procedure: For all other grievances,
we will make a decision and notify you
of our decision as your case requires based on your
health status, but not later than 30 calendar
days after receiving your complaint. We may extend the
timeframe by up to 14 calendar days if
you request the extension, or if we justify a need for
additional information and the delay is in
your best interest. |
|
| For quality of care problems, you may also complain to
the QIO |
If you are concerned about the quality of care you
received, including care during a hospital stay,
you can also complain to an independent organization
called the QIO. See
Section 1 of the EOC* for more information about the
QIO. |
|
| Molina Medicare is an
organization with a Medicare contract. This contract is
renewed annually, and coverage beyond the end of the
contract year is not guaranteed. |
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