Molina Healthcare appeal processes follow state Medicaid rules. Deadlines typically range from 30 to 60 days from the denial notice. After exhausting Molina's internal appeal, members and providers can request a state Medicaid fair hearing.
Day 1: Receive denial. Days 1-10: Review denial reason and gather documentation. Day 11-15: Submit appeal. Days 16-45: Molina review. Day 46: Written decision. If denied again: request state fair hearing within 120 days.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification absent | No auth on file | Obtain PA before service |
| CO-11 | Medical necessity | Insufficient clinical justification | Include detailed clinical notes |
| CO-50 | Non-covered service | Not in state Medicaid benefit | Verify coverage before service |
First-level appeal: submit within 30-60 days (state-specific). Molina responds within 30-45 days. If denied, request a state Medicaid fair hearing. Fair hearings are conducted by an administrative law judge. Decisions are binding on Molina.
It depends on your state's Medicaid rules. Most states allow 30-60 days from the denial notice date. Check the denial letter for your specific deadline, or contact Molina provider services.
Include: the denial notice, original claim, clinical documentation supporting medical necessity, any prior authorization documentation, and a provider letter explaining why the denial should be overturned.
Yes. After exhausting Molina's internal appeal process, you or the member can request a state Medicaid fair hearing. Filing deadlines vary by state, typically 120 days from the denial or 90 days from the appeal decision.
Altair tracks Molina appeal deadlines by state and prepares documentation for faster resolution.