Molina Healthcare billing: timely filing limit, appeals and denials
Molina's timely filing limit is 365 calendar days in its Ohio Medicaid provider manual, updated November 2024, counted from discharge for inpatient services and from the date of service for outpatient services. Molina publishes a separate manual for each state and product, and its Wisconsin Medicaid dental appendix for 2025 uses 90 days. Name the state, product and year before you quote any figure.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · Last reviewed October 2026In short: read the manual for the member's state and product. Ohio Medicaid allows 365 days to file a claim, 365 days from the remit date to correct it, and 365 days from service or 60 from remittance (whichever is later) to dispute it. Wisconsin dental is 90 days.
Molina Healthcare filing, prior authorization and portal
Appeal levels
Top denials from Molina Healthcare
| Code | Meaning | Our fix |
|---|---|---|
| Filing limit | Claim received after 365 days | Prove timely receipt with the clearinghouse acceptance report. See CO-29. |
| No authorization | Inpatient stay without a complete request | Check the extenuating circumstances list, then file a Clinical Claim Dispute. See CO-197. |
| Wrong channel | Correction sent as a dispute or on paper | Resend as an electronic corrected claim with the original claim ID. |
| Returned claim | Frequency or resubmission code missing | Add the code from the NUCC or UB editor values and resubmit. |
| Other insurance | Primary EOB missing | Attach the primary EOB in Availity or report COB data on the claim. |
What is the Molina Healthcare timely filing limit?
In Molina's Ohio Medicaid provider manual (last updated November 2024), a clean claim is due within 365 calendar days after discharge for inpatient services or the date of service for outpatient services. The manual cites Ohio Administrative Code Rule 5160-1-19. Other Molina states and products set their own limits, so use the manual for the state and product on the member's card.
| Claim type | Molina Healthcare of Ohio, Medicaid (manual updated 11/2024) |
|---|---|
| Original claim | 365 days from the date of service, or the filing limit in your provider contract. Inpatient claims count from discharge. |
| Corrected claim | 365 days from the remit date of the claim being corrected |
| Molina is secondary | The greater of the original window or 90 days from the date on the primary payer's EOB |
| Primary payer is not Molina | 90 calendar days after the primary payer's final determination |
Our state pages for Ohio, Michigan, Wisconsin and Washington name the Molina plan in each of those states. A claim sent after the window denies as CO-29. Date counting is in timely filing limits by payer.
How do I submit and check Molina claims?
Participating providers submit through Molina's Availity Essentials portal or through the Ohio Department of Medicaid's OMES EDI process. The Ohio manual asks for electronic submission whenever possible and uses payer IDs that depend on the line of business.
| Line of business (Ohio manual, dates of service on or after Feb. 1, 2023) | Payer ID |
|---|---|
| Ohio ABD, Adult Extension and Healthy Families (Medicaid) | 0007316 |
| Ohio Marketplace Program | 20149 |
| Medicaid, dates of service before Feb. 1, 2023 | 20149 |
- Status: use the Availity Essentials portal at provider.molinahealthcare.com. Provider Services is (855) 322-4079, 7 a.m. to 8 p.m., Monday through Friday.
- Format: the manual points providers to the ODM 837I and 837P companion guides on medicaid.ohio.gov to avoid claim rejections.
- Secondary claims: attach the primary carrier's EOB in Availity, or report the carrier name, ID, paid amount, disallowed amount with CARC or RARC, and paid date on the electronic claim.
How do I send a corrected or voided claim to Molina?
In the Ohio manual a corrected claim is treated as a new claim, sent electronically within 365 calendar days of the most recent adjudicated date, with the original Molina claim ID and the right frequency or resubmission code. Paper corrected claims are not accepted, and a correction sent through the dispute process is rejected.
- Send it through Availity Essentials or OMES EDI, marked as a replacement of prior claim or corrected claim on an 837I, or with the resubmission code on an 837P.
- Include the original Molina claim ID or last paid claim number and every element, both the ones you corrected and the ones you did not.
- Take the frequency or resubmission code values from the NUCC manual for the CMS-1500 or the UB editor for the UB-04.
- To void, use the void steps in the Help and Training section of Availity or the ODM materials the manual points to. Claims sent without the correct coding come back for resubmission.
What are the Molina appeal levels and deadlines?
For Ohio Medicaid, Molina's manual separates disputes by what you are disputing. A Non-Clinical Claim Dispute covers a payment denial, payment amount or code edit, and it must be filed within 365 days of the date of service or 60 days from the remittance advice, whichever is later. Authorization and medical necessity disputes follow their own tracks with their own clocks.
| Dispute | Deadline | How | Answer time |
|---|---|---|---|
| Non-Clinical Claim Dispute (payment denial, amount or code edit) | 365 days from date of service, or 60 days from remittance, whichever is later | Availity, fax with the Claim Reconsideration Form, or by phone | 15 business days |
| Authorization Appeal (before a claim exists) | 30 calendar days from the denial date, or until the claim is received | Fax only, not the portal | 48 hours urgent, 10 calendar days other |
| Clinical Claim Dispute (after a claim) | 365 calendar days from date of service or 60 days from remittance, whichever is greater | Availity under Appeals in Payer Spaces, or fax | See Molina's Authorization Appeal and Claim Dispute guide |
| Provider-represented Member Appeal | 60 calendar days from the authorization denial notice | One appeal, with the Authorized Representative Form | 15 calendar days for a standard member appeal |
The manual adds that once a determination is rendered, no further disputes are available with Molina. Primary insurance EOBs and itemized statements are not accepted through a Non-Clinical Claim Dispute; they go in as corrected claims.
Can I appeal a missing authorization after the service?
Yes, in listed extenuating circumstances. Within 60 calendar days of the claim denial or 365 days of the date of service, whichever is greater, a provider may file a Clinical Claim Dispute even though no authorization was requested in advance.
- A newborn stays an inpatient longer than the mother and needs a separate authorization.
- The member arrived unconscious or unable to give insurance information. Molina needs the registration face sheet, an explanation of why the information could not be obtained, and reviews six months of claims and authorization history.
- Retro-enrollment or a retro coordination of benefits change makes Molina the primary carrier.
Name the circumstance on the reconsideration form and attach the supporting documents and clinical information. This is the Ohio Medicaid rule; verify the state and product first.
Does Molina require prior authorization?
Emergent and urgent care is covered without authorization in the Ohio Medicaid manual, including at non-contracted providers. Other services depend on the Prior Authorization Code Lookup Tool on Molina's provider site. The manual requires pre-service review for all non-emergent inpatient admissions, outpatient surgery and identified procedures, home health, some DME and out-of-area or out-of-network professional services.
- Inpatient: all inpatient admissions require prior authorization, requested within two business days of the order. Include the practitioner order, clinical notes from a 48-hour observation period, the reason and the estimated length of stay.
- Observation: no authorization or admission notification for network providers. Out-of-network services always require authorization, including observation days.
- Submit: Availity Essentials is preferred, with a fax form as the alternative. Expedited initial requests are decided within 48 hours and standard requests within 10 calendar days.
- Peer-to-peer: call Utilization Management at (855) 322-4079 with two possible times. If it does not change the outcome, request an Authorization Appeal or Clinical Claim Dispute with new clinical information.
Denials for missing authorization map to CO-197; our prior authorization page covers front-end work. A July 1, 2025 addendum to the Ohio manual changed the out-of-network post-stabilization wording to say such services "may not be covered."
What does Molina require from hospitals, and how are overpayments handled?
| Topic | What the manual says |
|---|---|
| Planned admissions | Prior authorization for all elective or scheduled inpatient procedures at any facility. After the admission, notify Molina within 24 hours or by the next business day for concurrent review. Elective inpatient services without authorization may not be paid |
| Concurrent review | Molina asks for updated clinical records at intervals and needs them within 24 hours of the request. Missing updates can lead to denial of authorization for the rest of the stay, depending on the contract |
| Inpatient versus observation | Molina authorizes inpatient care when the record supports a continued stay, and expects observation to have been tried first and to have failed. At discharge, send the discharge summary with demographics, discharge date, plan and instructions, and disposition |
| Decision times for authorization requests | Expedited requests within 48 hours including weekends and holidays. Standard requests as soon as medically indicated, within a maximum of 10 calendar days |
| Overpayment notice | The July 1, 2025 addendum gives 60 calendar days from the date on the notice to dispute an overpayment or ask for a payment arrangement, up from 30. Without a written response, Molina may recover as the notice says |
| Where overpayment disputes go | Molina's Claims Recovery Department, Provider Disputes, PO Box 2470, Spokane, WA 99210-2470, or Availity under the standard claim dispute process |
What are the common causes of Molina claim denials?
The Ohio manual does not publish a reason-code table, so these are the denial patterns it describes.
- Timely filing: the claim arrived after 365 days, or a corrected claim after 365 days from the remit date.
- Wrong channel: a correction sent through a dispute, a paper corrected claim, or an EOB and itemized statement sent in a Non-Clinical Claim Dispute.
- Inpatient without authorization: admissions without a complete request and clinical documentation may be denied, except in extenuating circumstances.
- Coding: claims sent without the right frequency or resubmission code are returned.
- Other insurance: the primary carrier's EOB is required when Molina is secondary.
How do Molina rules differ by state and product?
Molina publishes a separate manual for each state and product, and the figures differ. This table keeps what we read apart.
| Plan and document | Filing limit | Disputes |
|---|---|---|
| Ohio Medicaid, provider manual updated 11/2024 (addendum July 1, 2025) | 365 days from discharge or date of service | Non-Clinical Claim Dispute: 365 days from date of service or 60 days from remittance, whichever is later |
| Wisconsin Medicaid, dental provider appendix, 2025 (updated 1/2/2025) | 90 days from date of service (dental claims, payer ID SKYGN) | 90 calendar days from Molina's original remittance date, then the state Department of Health Services within 60 calendar days of Molina's final decision |
The Wisconsin appendix covers dental claims only. Other Molina states are on our Michigan and Washington pages. For comparison read CareSource and Ambetter, or return to all payer guides.
- Molina Healthcare of Ohio Medicaid Provider Manual (updated 11/2024, addendum July 1, 2025) · Molina Healthcare
- Molina Healthcare of Wisconsin Medicaid Dental Provider Manual Appendix, 2025 · Molina Healthcare
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01What is the Molina Healthcare timely filing limit for claims?
In Molina's Ohio Medicaid manual, updated November 2024, it is 365 calendar days after discharge for inpatient services or the date of service for outpatient services. Corrected claims also have 365 days from the remit date. Molina's Wisconsin Medicaid dental appendix for 2025 uses 90 days from date of service, so check each state and product.
02What are the Molina Healthcare appeal levels and deadlines for a denied claim?
In Ohio Medicaid, a Non-Clinical Claim Dispute is due within 365 days of the date of service or 60 days from remittance, whichever is later, and is answered in 15 business days. Authorization Appeals are faxed within 30 calendar days of the denial. Clinical Claim Disputes follow the 365 or 60 day rule.
03How do I check eligibility and submit prior authorization for Molina Healthcare members?
Molina's Ohio manual puts eligibility verification on the provider, before services are rendered. Submit authorizations through Availity Essentials, the preferred route, or by fax form, after checking the Prior Authorization Code Lookup Tool. Inpatient admissions need authorization within two business days of the order. Emergent and urgent care needs none.
04What are the most common Molina Healthcare denial reasons for hospital and ER claims?
From Molina's Ohio Medicaid manual: filing after 365 days, inpatient admissions without a complete authorization request, corrected claims sent by paper or through a dispute, missing frequency codes, and missing primary EOBs. Emergency care itself needs no authorization, including at non-contracted providers.
05How do I dispute an out-of-network underpayment from Molina Healthcare through open negotiation and IDR?
For a Molina Ohio Medicaid payment amount you disagree with, use the Non-Clinical Claim Dispute within 365 days of the date of service or 60 days of remittance. Open negotiation and federal IDR depend on the member's plan type, so confirm that first. Our open negotiation page lists the federal deadlines.
06Which portal or clearinghouse do I use to submit claims and check status with Molina Healthcare?
Molina's Ohio manual names the Availity Essentials portal at provider.molinahealthcare.com, or the Ohio Department of Medicaid's OMES EDI process through a clearinghouse. Ohio Medicaid lines use payer ID 0007316 and the Ohio Marketplace program uses 20149. Check claim status in Availity or call Provider Services at (855) 322-4079.
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