Molina Healthcare of Ohio, Inc. claim denials in Ohio: the federal figures
Molina Healthcare of Ohio, Inc. denied 22.5% of in-network claims in Ohio — 137,574 claims out of 611,173. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Molina Healthcare of Ohio, Inc.) | 546 | 35% |
| External review (independent) | 15 | — |
What Molina Healthcare of Ohio, Inc. denies most
The most common denial reason recorded for Molina Healthcare of Ohio, Inc. plans in Ohio is not medically necessary. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Not medically necessary | 135,301 | 17.9% |
| Administrative reason | 118,568 | 15.7% |
| Referral required | 112,293 | 14.9% |
| Benefit limit reached | 108,178 | 14.3% |
| Other reasons | 106,734 | 14.2% |
| Service excluded from the plan | 97,565 | 12.9% |
| Member not covered | 61,882 | 8.2% |
| Provider out of network | 12,778 | 1.7% |
| Experimental or investigational | 776 | 0.1% |
What to do if Molina Healthcare of Ohio, Inc. denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. Molina Healthcare of Ohio, Inc. overturned 35% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Molina Healthcare of Ohio, Inc.. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your Molina Healthcare of Ohio, Inc. appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is Molina Healthcare of Ohio, Inc.'s denial rate high?
22.5% against a national average of 16% across the plans in this dataset. It is above average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can Molina Healthcare of Ohio, Inc. ignore the external decision?
No. External review decisions are binding on the plan.