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  • Molina Healthcare Of New Mexico, Inc. Provider Reconsideration ...

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MOLINA HEALTHCARE OF NEW MEXICO, INC. PROVIDER RECONSIDERATION REVIEW REQUEST (PRR) FORM Please print or type the following information: Practitioner/Provider Name: / TIN: Requestor name and title.

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How do I file an appeal? If you have received a Notice of Agency Action, instructions for requesting an appeal are included on the notice. If you have not received a notice, contact 2-1-1 or visit your local office. An appeal may be requested in person, by phone, fax or mail.

If you receive a Notice of Action from Molina Healthcare, you can file an appeal. A Notice of Action is a formal letter telling you that a medical service has been denied, deferred or modified. Medicaid members have 60 days to appeal from the date on the Notice of Action letter.

To file an appeal, you can: Call Member Services (888) 483-0760 (TTY/TDD: 711), Monday thru Friday from 9:00 a.m. to 5:00 p.m., local time.

You have 90 calendar days after the date of Molina's denial letter to ask for an appeal.

Medical Necessity Denials A practitioner/provider must submit a written appeal within 90 calendar days of the claims denial notification.

P. O. Box 165089 Fax Number: 1-877-816-6416 Irving, TX 75016 Page 2 Molina Healthcare Member Grievance/Appeal Request Form Molina Healthcare cannot promise that the way in which you submit this form to us is a secured method.

Corrected Claims must be sent within 180 calendar days of the original Claim paid date. Corrected claims must be submitted within 24 months of the original claim remittance advice date.

A written appeal request with all required documentation must be received by Medical and Utilization Review (UR) Appeals within 120 calendar days of the date of the decisions letter.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232