Insurance Denial Report

Molina Healthcare denies 22.4% of claims.
Here's how patients are fighting back.

Data from the 2023 CMS Marketplace Transparency Report. The national average is 19.1%. Molina denies claims at 3.3 points above average.

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22.4%
Claims denied
3.3pts
Above national avg
55%
Appeals overturned
15
States they operate in

What Molina Healthcare's denial rate means for patients

Molina Healthcare has a health insurance claim denial rate of 22.4%, which is higher than the national average of 19.1%. This means that nearly one in four claims submitted by patients may be denied, which can be frustrating and disheartening. Understanding these statistics is crucial for patients navigating their healthcare options. Knowing the denial rates can help you prepare and advocate for your health needs effectively.

The good news is that appeals are a viable option for patients facing claim denials. In fact, 55% of appeals submitted to Molina Healthcare are overturned in favor of the patient. This statistic highlights the importance of not giving up when faced with a denial. Patients have the right to appeal decisions, and with the right approach, many can successfully overturn denials and receive the care they need.

What Molina denies most often

Denial rates by treatment category, compared to the national average (19.1%).

GLP-1 Medications (Ozempic, Wegovy)
vs. ~19% avg
38%
Specialty Medications
vs. ~19% avg
30%
Mental Health
vs. ~19% avg
25%
MRI / CT Scans
vs. ~19% avg
18%

Molina's most common denial reasons

  1. 1Not medically necessary
  2. 2Service not covered by plan
  3. 3Prior authorization not obtained
  4. 4Lack of clinical documentation
  5. 5Formulary drug alternative available

How to appeal a Molina Healthcare denial

If you receive a denial from Molina Healthcare, it's essential to act promptly. You typically have 180 days to file an appeal, so start by gathering all relevant documentation. Make sure to request the clinical criteria that Molina used to make their decision, as this will help you understand their rationale. Additionally, consider requesting a peer-to-peer review with their medical director, which can provide a direct line of communication regarding your case. Send your appeal to the address provided in the denial letter, and keep copies of everything you submit for your records.

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Frequently asked questions about Molina Healthcare denials

How long do appeals take with Molina Healthcare?
Appeals with Molina Healthcare typically take 30 days for standard cases. However, if your situation is urgent, you may qualify for an expedited appeal, which can be resolved within 72 hours.
What documentation helps most when appealing a denial?
When appealing a denial, it's crucial to include any supporting medical records, a letter from your healthcare provider explaining the necessity of the treatment, and any other relevant documentation that aligns with Molina's clinical criteria.
What should I do if my first appeal is denied?
If your first appeal is denied, don't be discouraged. You can file a second-level appeal or request a review by an independent external reviewer. Make sure to gather additional evidence or documentation that strengthens your case.
Do I need an attorney for my appeal?
While it's not necessary to hire an attorney for your appeal, some patients find it helpful, especially for complex cases. An attorney experienced in healthcare law can provide guidance and support throughout the process.
GLP-1 appeal guide →MRI denial guide →How to appeal guide →Full resource center →

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