How do I?
Here are some answers to our most commonly asked questions.
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How do I file a Quality of Care Concern with Molina?
If you are unhappy with the care or services you or your family member received from a network provider or a facility,
we want to know. You or someone you appoint to act for you, may contact the Quality Management Department.
There are several ways to file a quality of care concern:By phone: Call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday - Friday 8am to 6pm local time/MST.
By completing a Quality of Care Referral form and emailing or mailing the form to us.
By email: MCCAZ-QOC@MolinaHealthcare.com
By mail: Send a letter to:
Molina Healthcare
Attn: Quality Management Department
5055 E Washington St, Suite 210
Phoenix, AZ 85034Call us if you need help with filing a Quality of Care Concern.
Molina works with a large number of doctors and providers in central Arizona. If they are in our Molina provider network, we can help you set up an appointment with them.
If your doctor or provider isn’t in our network, we can reach out to them to see if they would like to join.
Finding a doctor provider is easy with Molina. You can use our Provider Online Directory to look for a provider near you. You can also call Member Services and our team will be happy to help you find the right provider for you.
Yes. You can use our Provider Online Directory to search for a different doctor/provider near you. Once you’ve found a doctor/provider, you can call our Member Services team and let us know the name of the doctor/provider you would like us to assign to you.
You can learn how to get your medicine(s) and more on our benefits and services page.
Yes, as an Molina member, you can get a ride at no cost to any covered service. To schedule a ride, please call our Member Services team. You will be asked to choose your preferred language to start. Once you do, you will press “4” for member, followed by “1” to schedule a ride. Please call at least 72 hours before your visit.
There are some treatments, services and drugs that you need to get approval for before you get them or continue receiving them. This is called a prior authorization. You, your doctor, or someone you trust can ask for a prior authorization. An approval helps let us know if certain services or procedures are medically needed.
Molina discusses some services with your providers before you get them to make sure they are appropriate and needed. Your provider will help you in getting a service authorized from Molina when services need to have an authorization in place.
Some examples of services that need prior authorization are outpatient surgeries, medical supplies (i.e. wheelchairs), a stay in the hospital, pain management, transplants, orthotics and prosthetics. If you have any questions about what needs a prior authorization, call Member Services at (800) 424-5891 (TTY/TDD: 711).
Many services don’t need an authorization. Molina does not reward providers or our own staff for denying coverage or services.
Decisions are based on what is right for each member and on the type of care and services that are needed.
We look at standards of care based on:
- Medical policies
- National clinical guidelines
- Medicaid guidelines
- Your health benefits
Molina does not reward employees, consultants, or other providers to:
- Deny care or services that you need
- Support decisions that approve less than what you need
- Say you don’t have coverage
An authorization is not a guarantee of payment. Members must be eligible at the time services are rendered. Services must be a covered health plan benefit and medically necessary with a prior authorization as per plan policy and procedures. It is the responsibility of the member/provider to check for changes in the prior authorization requirements.
Medical necessity criteria
Molina has a review team to be sure you receive medically necessary services. Doctors and nurses are on this team. Their job is to be sure the treatment or service you asked for is medically needed and right for you. They do this by checking your treatment plan against medically acceptable standards.
The standards we use to determine what is medically necessary are not allowed to be more limiting than those that are used by AHCCCS. Any decision to deny a service authorization request or to approve it for an amount that is less than requested is called an adverse benefit determination (decision). These decisions will be made by a qualified health care professional.
If we decide that the requested service is not medically necessary, the decision will be made by a medical or behavioral health professional who may be a doctor or other health care professional that typically provides the care you requested.
You can request the specific medical standards, called clinical review criteria, used to make the decision for actions related to medical necessity.
After we get your request, we will review it under a standard or expedited (fast) review process. You or your doctor can ask for an expedited review if you think that a delay will cause serious harm to your health.
If your request for an expedited review is denied, we will tell you and your case will be reviewed under the standard review process.
Time frames for service authorization decisions
Time frames for standard requests
Molina issues service authorizations for medicines no later than 24 hours from the time we get the request, even if the due date falls on a weekend or a holiday. If we need more information, we will ask for the additional information from the prescriber within 24 hours. The final decision will be sent no later than seven business days from the date of the request.
Molina issues service authorization decisions on requests that are not related to prescriptions as quickly as the member’s condition requires, but no later than 14 calendar days from the initial request. If we need more information to make a decision, we may issue a notice of extension for an additional 14 calendar days.
Time frames for expedited requests
Molina issues expedited service authorizations as quickly as the member’s health condition requires, but no later than 72 hours from the date of receipt, even if the date falls on a weekend or holiday. We may issue a notice of extension for an additional 14 calendar days if Molina needs more time to review your request. For information on the criteria we use to make this decision, please call Member Services at 800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am to 6 pm local time/MST.
If the expedited request doesn’t meet the requirements for an expedited review, we may treat your request as a standard request. If you disagree with this decision, you may file a grievance either by calling Member Services or mailing your grievance to:
Molina Healthcare
Attn: Appeals and Grievances Department
5055 E Washington St, Suite 210
Phoenix, AZ 85034If we do not meet the time frames for making a decision, your request for an expedited decision is denied, or you will get a Notice of Adverse Benefit Determination (NOA). This letter will explain your rights to file an appeal.
For information about the prior authorization process, time frames for making a decision and your rights, please call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday-Friday 8 am-6 pm local time/MST.
Molina uses nationally accepted, evidence-based criteria, developed by specialty organizations, national policy committees (clinical practice guidelines) and/or industry recognized review organizations in addition to State or Federal criteria or regulations (as appropriate), medical policy or internally developed criteria, physician and clinical judgement to evaluate the necessity of medical and behavioral health services. Molina has adopted evidence-based clinical practice guidelines or protocols for a wide variety of medical conditions and services delivered in different medical and/or behavioral health settings. Molina has adopted MCG evidence-based clinical practice guidelines for management of medical, behavioral, home health, and nursing facility services.
Medical criteria is approved and reviewed annually by the Molina Medical Management Committee and National Policy Committee. In accordance with 42 CFR §438.236 Molina utilizes ASAM criteria for medical necessity determinations for Addiction and Recovery Services. Molina utilizes proprietary diagnostic services criteria for imaging, sleep studies, and certain pain management procedures. These criteria sets are based on sound scientific evidence for recognized settings of care and used to decide the medical necessity and clinical appropriateness of services. If state law requires additional criteria, it is adopted into policy and used.
Molina adopts practice guidelines that meet the following requirements:
- Are based on valid and reliable clinical evidence or a consensus of health care professionals and service providers in a particular field;
- Consider the needs and preference of the members;
- Are adopted in consultation with providers; and
- Are reviewed and updated periodically, as appropriate.
Molina disseminates any revised practice guidelines to all affected providers and, upon request, to members and potential members. The practice guidelines provide a basis for consistent decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply.
View the Molina Clinical Practice Guidelines
Sometimes you may get a decision or something may happen that you don’t agree with. If this happens, you may file a grievance or appeal with Molina Healthcare (Molina).
How do I file a grievance with Molina?
If you’re unhappy for any reason with Molina, your provider or your services, we want to know. You, or someone you appoint to act for you, should contact Member Services. The problem or concern you’re calling about will be handled as a grievance (another word for complaint). There are several ways to file a grievance:
By phone: Call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday - Friday 8 a.m. - 6 p.m. local time/MST.
By Molina Member Portal: https://member.molinahealthcare.com/
By mail: Send a letter to:
Molina Healthcare
Attn: Appeals and Grievances Department
5055 E Washington St, Suite 210
Phoenix, AZ 85034Call us if you need help with filing a grievance.
What happens after I file my grievance?
We’ll contact you letting you know we received and are working on your grievance. We’ll send a letter letting you know we received your grievance if you request that one be sent to you. We’ll try our best to deal with your concerns as quickly as possible and to your satisfaction. Whenever possible, we’ll resolve your issue within 10 business days and send you a letter with our response. If we need more information, we may take up to 90 days to resolve the grievance.
If you think you have not been treated fairly due to your race, color, age, national origin, sex, disability or religion, you can make a complaint to the Department of Health and Human Services’ Office for Civil Rights. For example, you can make a complaint about disability access or language assistance. You can also visit for more information.
Office of Civil Rights – Region III
Department of Health and Human Services
150 S Independence Mall West Suite 372
Public Ledger Building
Philadelphia, PA 19106
(800) 368-1019
Fax: (215) 861-4431
TDD: (800) 537-7697How do I file an appeal with Molina?
If we deny a request for a service or we reduce or end a service, we will send you a Notice of Adverse Benefit Determination that explains why. If you disagree with our decision, you can file an appeal asking us to take a second look at our decision.
Some reasons you might file an appeal are:
- You received a denial of services – this could be either a full or partial denial
- Care that was previously approved has been reduced or stopped
- You received a denial of payment for a service – either whole or in part
You can read more about the reasons to file an appeal in your Molina Member Handbook.
You must file the appeal within 60 days of the date on the Notice of Adverse Benefit Determination. There are several ways to file an appeal:
By phone: Call Member Services at (800) 424-5891 (TTY/TDD: 711) Monday - Friday 8 a.m. - 6 p.m. local time/MST.
By Molina Member Portal:https://member.molinahealthcare.com/
By mail: Send a letter to:
Molina Healthcare
Attn: Appeals and Grievances Department
5055 E Washington St, Suite 210
Phoenix, AZ 85034If you call us to file an appeal, you must also write to us within 10 days, unless you’re asking for an expedited appeal. If you choose to have someone else (like a family member or your provider) file the appeal on your behalf, we need your written permission. Call us if you need help with filing an appeal.
What happens next?
Molina’s standard appeal process
Molina will send a letter to let you know we have received and are working on your appeal. Appeals for clinical matters will be decided by qualified health care professionals who did not make the first decision and who have experience in the treatment of your condition or disease.
If you’d like to continue receiving these services while you wait for the appeal decision, you must file the appeal within 10 days of the date on the Notice of Adverse Benefit Determination or by the date the change in services is scheduled to occur. If our original decision is upheld and you received the services that are being appealed, you may have to pay for the cost of any continued benefits you received.
Before and during the appeal, you or your authorized representative can provide additional information you’d like us to review. You also have a right to view your case file, including medical records and any other documents being used to make a decision on your case. This information is available at no cost to you.
If Molina has all the information we need, we will make our decision within 30 days of the day we receive your appeal request. This is known as a standard appeal time frame. We’ll send you a Notice of Appeal Resolution telling you our decision within three business days after we make the decision.
If you need more time to get all the information to us, you can request an extension of up to 14 days. Molina may also request an extension for up to 14 days if we need more information. We will call you to tell you the reason for the extension. We’ll follow up with a written notice within two calendar days. You have the right to file a grievance if you disagree with the extension.
If you do not agree with our decision on your appeal, you can request a State Fair Hearing.
Requesting an expedited appeal from Molina
If you need a decision right away, please let us know it is urgent. This occurs when your health status is in danger. If we have all the information we need, we will give you an answer within 72 hours of your request. While you wait for our answer, you can continue to receive care. However, if the final decision is not in your favor, you may have to pay for the care. We will tell you our decision by phone and send a written Notice of Appeal Resolution within one business day from the date we make our decision.
If we determine that your appeal should not be expedited, we will call you to tell you that the appeal has been changed to a standard appeal. We will send you a written notice of this change within two calendar days of the reason for the decision. Molina will then resolve your appeal within the standard appeal time frames.
If you do not agree with Molina’s decision on your appeal, you can request an expedited State Fair Hearing. We will not treat you or your provider unfairly because you file an appeal.
State Fair Hearing request
If you do not agree with our decision on your appeal, you or your authorized representative can request a State Fair Hearing. You must request it in writing within 90 days from the date on the Notice of Appeal Resolution from us. You may also request a State Fair Hearing if Molina does not complete your appeal in a timely manner. Information about asking for a State Fair Hearing can be found in the Notice of Appeal Resolution letter we send you or by calling Member Services.
To ask for a State Fair Hearing in writing, send a letter to:
Molina Healthcare
Attn: Appeals and Grievances Department/SFH
5055 E Washington St, Suite 210
Phoenix, AZ 85034Molina takes every allegation of health care fraud, waste and abuse seriously. If you think a provider or someone else is committing fraud, waste or abuse, please report it.
What is fraud?
Fraud is intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to him or herself or some other person.
What is waste?
Waste is the overutilization and/or wrong use of services, resources or practices that result in unnecessary costs.
What is abuse?
Abuse is payment for items or services when there is no legal right to that payment whether or not it was obtained by someone knowingly or purposely misrepresenting facts.
What is the difference between health care fraud and health care waste or abuse?
The difference between fraud and waste or abuse is whether or not someone did it on purpose. Fraud is intentionally lying. The person knows that the information is false. Waste and abuse involve certain actions that don’t make sense. Waste and abuse cause payment for services that are not covered by the plan.
Examples of fraud, waste and abuse:
Providers:
- Providing medical services that are not needed
- “Up-coding” – charging for a more complex or expensive service than was given
- Billing for services that were not provided
- Lying about a patient’s diagnosis so they can get tests, surgeries or other procedures that aren’t needed
- Billing for rented medical equipment after it has been returned
- Billing twice for the same service
- Billing for more services than can be performed in one day
- Asking for, offering or getting money or something of value in exchange for referrals (e.g. a doctor paying a patient to refer other Medicaid members, or to get services that are not needed)
Members:
- Using another person’s name to get Medicaid services
- Sharing a member ID card or using another person’s member ID card
- Visiting several doctors to get multiple prescriptions
- Lying to a care coordinator or someone else to try and get a service you don’t need
- Paying a doctor cash for a prescription that is not needed
- Making false documents by changing:
- The date of service
- Prescriptions
- Medical records
- Referral forms
How can I report fraud, waste or abuse?
You can call the Molina AlertLine to report fraud, waste and/or abuse.
You can also report fraud by filling out the fraud, waste and abuse form online. Please give as much information as possible. You do not have to give your name. AHCCCS will not share your information with the provider.
Confidential hotline numbers (available 24 hours a day, 7 days a week):
AlertLine: (866) 606-3889
Online: MolinaHealthcare.alertline.comYou can also report fraud, waste or abuse concerns directly to the AHCCCS/Office of Inspector General (OIG) at:
- By email: AHCCCSFraud@azahcccs.gov
- By mail:
Office of the Inspector General
801 E Jefferson St.
Phoenix, AZ 85034 - AHCCCS Online Form: https://www.azahcccs.gov/Fraud/ReportFraud/onlineform.aspx
- Or using the hotline numbers at:
- To report suspected fraud by a medical provider, please call the numbers below:
- In Maricopa County: (602) 417-4045
- Outside of Maricopa County: 888-ITS-NOT-OK or 888-487-6686
- To report suspected fraud by an AHCCCS member, please call the numbers below:
- In Maricopa County: (602) 417-4193
- Outside of Maricopa County: 888-ITS-NOT-OK or 888-487-6686
- To report suspected fraud by a medical provider, please call the numbers below:
Molina is committed to doing business honestly, ethically and following all applicable laws and regulations. Molina’s Corporate Compliance department provides guidance on code of conduct issues, corporate policy and/or laws and regulations.
Health care fraud, waste and abuse prevention tips
You can help Molina stop fraud, waste or abuse by doing these things:
- Review your paperwork from your plan, such as your Explanation of Benefits or Service Verification surveys (if received). Make sure the following information is correct:
- Date of service
- Type(s) of service(s) reported
- Name of the provider billing for those services
- Protect your insurance card and personal information at all times. Do not share it with others.
- Count your pills when picking up a prescription.
- Report anything that seems wrong to Molina as soon as possible.
Molina Healthcare of Arizona, Inc. (Molina Healthcare) provides treatment to individuals experiencing behavioral health issues through the use of residential treatment by improving the individual's ability to be independent in the community. Molina follows the guidelines set forth in AHCCCS AMPM 320-V.