Molina Healthcare Claim Denied: How to Appeal Your Medicaid or Marketplace Denial

Molina Healthcare Claim Denied: How to Appeal Your Medicaid or Marketplace Denial

Molina Healthcare is a leading managed-care organisation serving over 5 million members primarily through Medicaid managed care and ACA marketplace plans in 19 states, including California, Texas, Florida, Ohio, Washington, and others. Molina focuses specifically on low-income and government-funded populations — which makes the stakes of a claim denial particularly high for the people it serves.

If Molina has denied your claim, you have legally guaranteed appeal rights that are often more extensive than people realise — including Medicaid-specific protections like state fair hearings and ombudsman assistance.

About Molina Healthcare

Molina primarily operates:

• Medicaid managed care (the largest segment) — serving Medicaid and CHIP beneficiaries in most of its states
• ACA marketplace plans (individual and family plans in select states)
• Medicare-Medicaid Plans (Duals) — serving people eligible for both Medicare and Medicaid

The type of plan you have determines which appeal rules apply. Medicaid managed care has its own federal and state-specific rules, in addition to standard ACA appeal rights.

Common Molina Denial Reasons

Medical necessity denials: Molina's clinical reviewers determine whether services meet their medical necessity criteria. Common examples:

• Hospital admissions Molina argues should be outpatient
• Specialist referrals
• Mental health and substance use treatment (particularly intensive outpatient and residential treatment)
• Medical equipment and supplies (wheelchairs, CPAP machines, prosthetics)
• Certain medications not on Molina's formulary

Prior authorization denials: Molina requires prior authorization for many services. Denials can happen both at the authorization stage and after services are rendered if authorization wasn't obtained.

Service not covered: Molina plans (especially Medicaid) have defined benefit packages. Some services — dental, vision, certain therapies — may not be covered depending on your state's Medicaid program and your specific plan.

Step therapy denials: Molina may require you to try a lower-cost medication before approving your prescribed drug.

Coordination of benefits issues: If you have both Medicaid and another insurance plan, coordination of benefits disputes can cause denials.

Eligibility disputes: Molina may question your eligibility for a particular service or benefit level, especially as Medicaid eligibility rules changed post-pandemic.

Your Appeal Rights

For Medicaid Managed Care Members

Medicaid members have additional appeal rights beyond standard ACA appeals:

1. Molina Internal Appeal (Grievance and Appeal):

• File a formal appeal with Molina within 60 days (or longer in some states) of the denial
• Molina must decide standard appeals within 30 days and expedited (urgent) appeals within 72 hours
• Molina must provide a written notice of appeal outcome

2. State Fair Hearing:

• If you disagree with Molina's appeal outcome (or if Molina fails to decide in time), you have the right to request a State Fair Hearing — an administrative hearing before an independent hearing officer from your state's Medicaid agency
• State fair hearings are a critical protection unique to Medicaid
• File your state fair hearing request with your state Medicaid agency (not Molina)
• Important: You can request a State Fair Hearing at the same time as your internal Molina appeal — you don't have to wait

3. Aid Pending (Continuation of Benefits):

• If you are already receiving ongoing services that Molina is trying to reduce, terminate, or modify, you may have the right to continuation of benefits ("aid pending") while your appeal is pending
• You must request this when filing your appeal

4. Medicaid Ombudsman:

• Many states have a Medicaid Managed Care Ombudsman or Patient Advocate who can assist Medicaid members with appeals at no cost
• Contact your state Medicaid agency to find your state's ombudsman

For ACA Marketplace Members

Standard ACA appeal rights apply:

• Internal appeal within 60 days (standard) or 72 hours (urgent)
• External review by IRO after exhausting internal appeal (binding on Molina)
• State insurance regulator complaint

Step-by-Step: Appealing a Molina Denial

Step 1: Review Your Notice of Action (NOA)

Molina must send you a Notice of Action (NOA) in writing explaining:

• What action Molina is taking (denial, reduction, termination)
• The reason for the action
• The clinical or regulatory basis
• Your right to appeal and the deadline

Read this carefully — the deadline to appeal is typically printed on the NOA.

Step 2: Contact Your Molina Care Manager (If Applicable)

If you have a Molina care manager or case manager assigned to you (common for complex conditions), contact them about the denial. Sometimes care managers can resolve denials by coordinating additional clinical information between your doctor and Molina.

Step 3: Gather Medical Evidence

• Letter from your treating physician explaining medical necessity
• Medical records supporting your diagnosis
• Any clinical guidelines from professional organisations supporting your treatment
• Documentation of any treatments you have already tried (for step therapy disputes)

Step 4: File the Molina Internal Appeal

Contact Molina:

• Phone: Call Member Services (number on your Molina ID card)
• Mail or fax: Address on your NOA
• Online: Molina member portal at molinahealthcare.com

State clearly that you are filing an appeal (not just a complaint). Include all supporting documentation.

For Medicaid members — also file a State Fair Hearing request: Contact your state Medicaid agency simultaneously. You don't need to wait for Molina's appeal outcome.

Step 5: Request Aid Pending (Medicaid Members)

If you are appealing a termination or reduction of ongoing services, explicitly request continuation of benefits while your appeal is pending. This must typically be done within 10 days of receiving the NOA.

Step 6: Request External Review or Attend State Fair Hearing

ACA members: After Molina's final internal denial, request external review from an IRO.

Medicaid members: Attend your state fair hearing. You can represent yourself or bring a representative (family member, advocate, or attorney — many legal aid organisations assist Medicaid members for free).

Step 7: Contact Your State Medicaid Ombudsman

Your state's Medicaid ombudsman or patient advocate can provide free assistance navigating the appeal process, help you prepare for a state fair hearing, and apply regulatory pressure on Molina.

Molina-Specific Appeal Timelines

Action	Timeline
Molina internal appeal deadline	60 days from NOA (Medicaid) / 180 days (ACA)
Molina standard appeal decision	30 days (Medicaid) / 60 days (ACA)
Molina expedited appeal decision	72 hours
Aid pending request deadline	10 days from NOA
State fair hearing request	Per state rules (typically 90–120 days from NOA)

Key Tips for Molina Appeals

Know which plan type you have: The appeal rules differ significantly between Medicaid managed care and ACA marketplace plans. Identify your plan type first.

Use free legal help: Many states have legal aid organisations that provide free assistance for Medicaid appeals. Contact your local legal aid society or state Medicaid ombudsman.

Mental health parity: If your denial involves mental health or substance use disorder services, the federal MHPAEA prohibits Molina from applying more restrictive criteria than it applies to comparable medical services.

Keep records of everything: Note dates, times, names of representatives you speak with, and reference numbers for every call and document submitted.

Conclusion

Molina Healthcare serves some of the most vulnerable populations in the US, and a claim denial can have serious consequences. But Medicaid managed care members have powerful protections — including state fair hearings and ombudsman assistance — that go beyond standard ACA appeal rights. Don't accept a Molina denial without appealing. Use ClaimBack at claimback.app to generate a professional appeal letter, then escalate to a state fair hearing and your state's Medicaid ombudsman if needed.

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Related Reading:

• Medicaid Claim Denied: Your Rights and How to Appeal
• Oscar Health Claim Denied: How to Appeal
• How to Get Your Insurance Company to Respond
• What If Your Insurance Appeal Is Denied Again?