Who Is Molina Healthcare?
Molina Healthcare is one of the largest health insurance companies in the United States, managing millions of health plan members across commercial, Medicare Advantage, and Medicaid programs.
Denial Rate & Patterns
Based on CMS data and state insurance commissioner reports, Molina Healthcare denies approximately 21% of claims. This is significantly higher than the industry average of 19% and higher than most competitors.
Molina Healthcare's denial rate reflects their aggressive medical review practices and tight documentation requirements. Their decision logic prioritizes cost containment early in the authorization process.
Most Common Denial Reasons
- Medical Necessity (45%) — Documentation deemed insufficient to prove procedure was necessary
- Prior Authorization (25%) — Authorization not obtained or expired
- Experimental/Investigational (15%) — Procedure deemed not standard of care
- Conservative Treatment Not Exhausted (10%) — Non-surgical options not fully documented
- Facility/Provider Issues (5%) — Out-of-network or non-credentialed provider
Winning Appeal Strategies for Molina Healthcare
Molina Healthcare physicians respond well to peer-to-peer discussions. Request this before escalating to external review.
Molina Healthcare's bar for "sufficient documentation" is high. Include imaging, test results, functional limitation assessments, and clinical notes.
Molina Healthcare often cites internal clinical policies that differ from national guidelines. Cite national guidelines (ACCF/AHA, AAOS, NCCN) directly in your appeal.
Molina Healthcare commonly denies because they claim conservative treatment wasn't exhausted. Get detailed documentation of PT, injections, or other conservative attempts.
Molina Healthcare is responsive to state insurance commissioner complaints. Mention this in your appeal to accelerate their response.
Top Procedures Molina Healthcare Denies Most
- Medicaid procedures
- general surgery