Receiving a Molina Medi-Cal denial can feel like the end of the world. When you are sick or injured, everything seems magnified and this can seem like an overwhelming problem. This is a time when you need the best, most experienced attorney in the business. Scott Glovsky has been helping people in similar situations for his entire career. Scott really cares about clients, their families, and their futures. When facing an insurance denial don’t give up—call attorney Scott Glovsky.
What Are Medi-Cal Plans?
Medi-Cal Plans are essentially for Californians with low incomes or no income. Some of those with Medi-Cal are in what is known as a Managed Care Plan with networks of providers, including hospitals, doctors, labs, clinics, and pharmacies. The basic benefits covered by most health plans are covered under Medi-Cal, which also covers prescription drugs, hearing care, and vision care. The providers in your Medi-Cal network must be used when you are a member of Medi-Cal. Most of your healthcare needs will be attended to by your primary care doctor (PCP), which could be chosen for you when you sign up.
You are allowed to change your PCP as well as the clinic you go to, so long as they are in-network. Medi-Cal plan options will vary according to the county you live in. Most counties will offer commercial Medi-Cal plans including Health Net, Molina, Anthem Blue Cross, Kaiser Permanente, Promise, and more. Some counties may offer public plans administered by the community—if the county only administers one plan, then all Medi-Cal members will be enrolled in that plan. Most Medi-Cal plans fall under “managed care,” meaning they function in the same way as an HMO.
What Counties Offer Molina Medi-Cal Managed Care Plans?
Molina has Medi-Cal Managed Care plans in Riverside, Sacramento, San Bernadino and San Diego. It partners with Health Net in Los Angeles.
Do Molina Medi-Cal Managed Care Plans Work with Independent Physician Associations (IPA)?
Many Molina Medi-Cal Managed Care plans work with IPAs. Independent Physician Associations are independent medical groups that have their own practices – sometimes even including facilities like hospitals. When a health insurance company works with an IPA, it typically has the IPA approve and deny medical care. Learn more about IPAs here. Based on information from 2020, specific IPAs are listed by county. A small sample of them include the following:
- Orange County: Heritage Provider Network includes Affiliated Doctors of OC, Regal Medical Group, and Lakeside Medical Group. Monarch Health Plan is another IPA,
- San Bernadino Counties: Regal Medical Group, Vantage Medical Group
- Imperial County: Imperial Valley Family Care Medical Group, Community Care IPA
- Los Angeles County: Preferred IPA of California, Regal Medical Group, Allied Pacific IPA, Healthcare LA IPA
- San Diego County: Vantage Medical Group, Integrated Health Partners, Community Care IPA
Molina Insurance Provider and Its Medi-Cal Plans
Molina Healthcare of California had about 628,118 Medi-Cal residents enrolled in 2021, covering Sacramento, Los Angeles, San Bernardino, Riverside, San Diego, Orange, and Imperial counties. In addition to “regular” healthcare services, Molina providers may also offer transportation services for emergency and non-emergency medical issues, an advice line staffed by highly knowledgeable nurses, Certified Nurse Midwife services, support for children, teens, and young adults to help them stay or get healthy, Community Health Worker programs, and even Doula services.
What Types of Services Might Molina Deny?
Molina Healthcare of California is headquartered in Long Beach, CA, and is a managed care company founded in 1980 by an ER doctor. Patients were often forced to use the ER for common illnesses because they were unable to find doctors who would accept Medi-Cal. Molina began opening clinics in California until 1997 when it expanded to other states. Molina went public in 2023 with an IPO exceeding $100 million. Like other health insurers, even though Medi-Cal is overseen at the state level by the Department of Health Care Services with individual cases managed at the local level, Molina may deny certain healthcare services.
While missing information, failure to obtain pre-approval when necessary, and errors in paperwork can all be responsible for a Molina Medi-Cal managed care denial, denials are more likely to stem from any medical procedure or medication that is costly. Molina may deny your claim by saying the procedure or medication is “not medically necessary,” or that the procedure or medication is “experimental” or “investigational.” These terms are often used when an insurer doesn’t want to pay for an expensive process or prescription medication. It can be demoralizing to receive a Molina Medi-Cal managed care denial for a procedure or drug that your doctor feels is necessary for your health.
What Steps Should You Take if Molina Denies Your Medi-Cal Claim?
If you’ve received a Molina Medi-Cal managed care denial, there are steps you can take that can potentially get the denial reversed. While this is a stressful time in your life, don’t give up! Having an experienced Molina Medi-Cal denial attorney like Scott Glovsky by your side can make the difference between a denial and a reversal of that denial. First of all, you need to find out why you received the Molina Medi-Cal managed care denial.
You should have received a denial letter from your insurance plan detailing why your claim was denied. A denial letter is sometimes called an “Adverse Benefit Determination (delay, modification, denial, etc.)”, If your ABD was the result of something simple, you can correct the mistake and resubmit the claim. If your Molina Medi-Cal managed care denial states that the treatment, procedure, or prescription drug was denied because it is experimental, investigational, or medically unnecessary, you should speak to your attorney about an appeal.
Get all the details you can from Molina so that you know exactly what steps need to be taken. Ask Molina to send you its criteria for coverage of what it denied. You can ask your healthcare provider to write a letter on your behalf that will state all the reasons the treatment is necessary for your health. Your attorney can help ensure you have all the necessary paperwork to file your appeal, including the claim denial letter, all bills and documentation related to the service, any notes you have from your phone calls with the insurance company, and your policy documents, including Evidence of Coverage or Summary of Benefits.
Your attorney can help guide you to submit an internal appeal that asks your insurer to take another look at the claim and reach a different decision. Molina’s appeal decision is called, “Notice of Appeal Resolution” and it tells you in writing if Molinaupheld or overturned its prior decision. The NAR also informs you how to ask for a state fair hearing if it upheld its earlier decision. Keep in mind that if Molina doesn’t get you its NAR appeal decision within 30 days (72 hours if the issue is urgent), then it is essentially a denial as of the day the ABD expired.
If you have not already received the treatment, Molina must decide within 30 days. If you’ve received treatment, the company has 60 days to reply, and if you’re appealing a claim denial for urgent care, your insurer must decide within 72 hours.
If the result of your internal appeal is denied, you have a few options. You can request an external review by a neutral third party, also known as an Internal Medical Review by the Department of Managed Healthcare.. Since the decision of your external appeal is binding on your insurer, we suggest speaking with an attorney prior to submitting an external appeal. Another option is to request a Medi-Cal Fair Hearing, which you can learn more about here.
How the Law Offices of Scott Glovsky Can Help With a Molina Medi-Cal Managed Care Denial
When you’ve received a Molina Medi-Cal managed care denial you need solid, experienced legal assistance. You need the Law Offices of Scott Glovsky. Scott and his legal team will fight for justice on your behalf, working hard to ensure you receive the medical treatments, prescription drugs, and tests your doctor believes are necessary and appropriate.
Scott began his career as a corporate attorney, which means he knows all the arguments a big insurance company may present as well as how to exploit their weaknesses. Scott is relentlessly tough when fighting for your rights, and relentlessly personal with his clients. The Law Offices of Scott Glovsky deliberately limits the number of cases taken so it can provide highly personalized service to each client. If you need help with a Molina Medi-Cal managed care denial, contact The Law Offices of Scott Glovsky today.