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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 1-800-665-3072 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 do not apply to Part D prescription drug
benefits. See
EOC* Section 12 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 Michigan 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 Michigan 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
Michigan/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 1-800-665-3072 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 Michigan 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).q |
| 2. |
Complaints about your
Part D prescription drug benefits that we will cover
or pay for. If Molina Healthcare of Michigan 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
EOC* Section 6 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 Michigan Peer
Review Organization, which is the Quality
Improvement Organization in the state of Michigan.
Michigan Peer Review Organization is a group of
health professionals in your state 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 Michigan Peer Review Organization,
which is the Quality Improvement Organization in the
state of Michigan. 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 Michigan, Inc./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 Michigan. But for many problems
related to quality of care you get from plan
providers, you can also complain to Michigan Peer
Review Organization. |
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Part 1. Complaints (appeals) to Molina Healthcare of
Michigan 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: |
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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
EOC* Section 11). |
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Step 1: The initial decision by Molina Healthcare of
Michigan |
| 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
EOC* Section 11, 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 Michigan |
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
EOC* Section 11, 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 Michigan. 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 $1,090.00 to go to a Federal
Court. |
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| For a more detailed explanation of all six steps
outlined above, see
EOC* Section 11. |
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| Part 2. Complaints
(appeals) to Molina Healthcare of Michigan to change a
decision about what Part D drugs we will cover or pay
for |
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This part
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 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 |
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| 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
EOC* Section 12). |
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| Step 1: The initial
decision by Molina Healthcare of Michigan |
| 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
EOC* Section 12, 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 Michigan |
| 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
EOC* Section 12, 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 |
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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
Michigan. 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 $1,090.00 to
go to a Federal Court. |
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| For a more detailed
explanation of all six steps outlined above, see
EOC* Section 12. |
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| Part 3. Complaints
(appeals) if you think you are being discharged from the
hospital too soon |
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| 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
EOC* Section 10 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. Review of your hospital discharge
by the Quality Improvement Organization |
| 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"? |
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"QIO" stands for Quality Improvement Organization. The
QIO, called Michigan Peer Review Organization in your
state, 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 Michigan or your
hospital. There is one QIO in each state. QIOs have
different names, depending on which state they are in.
The doctors and other health experts in Michigan Peer
Review Organization 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.
EOC* Section 1 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 Michigan 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
EOC* Section and in more detail in
EOC* Section 11. |
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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. (Unless the IRO overturns
our decision.) |
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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
EOC* Section 11. |
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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 of
EOC* Section 10 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
Michigan 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 Medicare/Medicaid Assistance Program (MMAP) for
a review in time? |
| You still have another
option: asking Molina Healthcare of Michigan for a "fast
appeal" of your discharge. |
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| If you do not ask MMAP
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
EOC* Section 11. |
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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, if MMAP does not
decide in your favor. If you do not ask MMAP 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
EOC* Section 11. |
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| Part 5. Complaints
(grievances) about any other type of problem you have
with Molina Healthcare of Michigan, Inc./Molina Medicare or one of our plan providers |
This last part of
EOC* 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 Services 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
Services 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 1-800-665-3072. 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 Healthcare of Utah
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 within
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. |
| |
| 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 no 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. "QIO" stands
for Quality Improvement Organization. See
EOC* Section 1 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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| |
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