Molina Healthcare of Wisconsin, Inc. claim denials in Wisconsin: the federal figures
Molina Healthcare of Wisconsin, Inc. denied 13.2% of in-network claims in Wisconsin — 13,822 claims out of 104,458. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to Molina Healthcare of Wisconsin, Inc.) | 258 | 34.9% |
| External review (independent) | — | — |
What Molina Healthcare of Wisconsin, Inc. denies most
The most common denial reason recorded for Molina Healthcare of Wisconsin, Inc. plans in Wisconsin is administrative reason. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Administrative reason | 10,952 | 27.4% |
| Service excluded from the plan | 9,392 | 23.5% |
| Benefit limit reached | 7,051 | 17.7% |
| Other reasons | 5,389 | 13.5% |
| Referral required | 4,334 | 10.9% |
| Provider out of network | 2,237 | 5.6% |
| Not medically necessary | 371 | 0.9% |
| Experimental or investigational | 95 | 0.2% |
| Member not covered | 87 | 0.2% |
What to do if Molina Healthcare of Wisconsin, 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 Wisconsin, Inc. overturned 34.9% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not Molina Healthcare of Wisconsin, 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 Wisconsin, 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 Wisconsin, Inc.'s denial rate high?
13.2% against a national average of 16% across the plans in this dataset. It is at or below 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 Wisconsin, Inc. ignore the external decision?
No. External review decisions are binding on the plan.