How to Appeal a Denial of Medicaid

Three Parts:Filing Written NoticeParticipating in MediationAttending Your Hearing

Federal and state governments provide the Medicaid program, which offers medical assistance for low-income people.[1] While the state agencies administer the benefits, they must follow federal law when handling Medicaid applications. If you apply for Medicaid benefits, your state agency may deny your application. When this happens, you have the right to file an appeal and have your application reviewed by a judge or other officer. If you win your appeal, you may be eligible for retroactive coverage including reimbursement of any out-of-pocket expenses you incurred for medical treatment that should have been covered by Medicaid.[2]

Part 1
Filing Written Notice

  1. Image titled Appeal a Denial of Medicaid Step 1
    Read your notice of action. If your state's agency denies your application for Medicaid benefits, it must send you a written notice explaining the reasons for the denial.
    • Federal law gives state agencies deadlines to send you written notice. If you applied for Medicaid because of a disability, the agency must send you notice within 90 days of the date on your application. If your application was for any other reason, the agency has 45 days.[3]
    • Your notice must provide the reasons your application was denied and the rules on which your state's agency relied when denying your application.[4]
    • Your notice also must include information about your right to appeal, including how to request a hearing and that you have the right to hire an attorney or another spokesperson such as a friend or relative to help you.[5]
    • After you've read your notice, make sure you keep it until the appeal is complete. You may need to refer to it later when you are preparing for your mediation or hearing.[6]
  2. Image titled Appeal a Denial of Medicaid Step 2
    Take note of your deadline to appeal. Your notice of action will include a deadline by which you must file an appeal.
    • Keep in mind that if you don't request your repeal before this deadline, you can't appeal unless you provide sufficient justification for a late appeal.[7]
    • The Medicaid agency will only approve a late appeal request for "good cause." For example, if you were so sick that you couldn't file the appeal yourself or get anyone else to do it for you, or if there was a death or serious illness in your immediate family.[8]
    • Deadlines differ from state to state, but it will be no more than 90 days from the date your notice of action was mailed.[9]
    • However, if you were denied on a single claim and want to continue to receive other Medicaid benefits pending your appeal, you may have as little as 10 days to make your appeal.[10]
  3. Image titled Appeal a Denial of Medicaid Step 3
    Fill out the appeal form. Your notice of action may come with a form you can fill out to appeal the denial.[11]
    • If instructions also are provided detailing how to complete and file the form, make sure you read them carefully before proceeding. Since each state's specific rules differ, these instructions are particular to your state's agency and your case.[12]
    • In some cases you may not be required to request an appeal in writing,[13] but it's generally better for you to do so anyway so there is a record of your appeal and the date you requested it.
    • If you weren't provided a form to fill out to request an appeal, you can simply write a letter to the state Medicaid agency that says "I request an appeal of my Medicaid denial."[14] Include the date of the notice and your full legal name and address.
    • Make a copy of your appeal request for your records before you submit it.
  4. Image titled Appeal a Denial of Medicaid Step 4
    Submit your form to your local agency. Your notice of action may include an address to which you can mail your form, or you may want to deliver it in person.
    • In some states, you may be required to submit your form to more than one agency. Your notice should detail precisely where the appeal request should be sent.[15]
    • If you mail your appeals request, consider sending it through certified mail with returned receipt requested, so you have a record of the date the agency received your request.
    • Keep in mind that the agency must receive your request by the deadline listed on your notice.[16]
    • If you have the ability to go to the local Medicaid office in person and submit your appeal, that's the easiest way to be sure it's received by the deadline. Just make sure that the person who accepts it date-stamps it so there is proof of when it is received.[17] Ask for a copy of your date-stamped appeal request so you have it for your records.
  5. Image titled Appeal a Denial of Medicaid Step 5
    Consider consulting an attorney. Although you have the right to represent yourself on appeal, you may benefit from having an experienced Medicaid attorney to help you.
    • You can check at local legal aid offices to find out about free or reduced-fee legal services if you think you require an attorney's services.[18]
    • Also keep in mind that many attorneys provide free consultations, so you can at least get a brief legal opinion on the strengths and weaknesses of your appeal before deciding whether hiring an attorney would be worth it.
    • If you're concerned about the cost of hiring an attorney, you also might consider having a friend or family member to work with you and represent you on appeal.[19]

Part 2
Participating in Mediation

  1. Image titled Appeal a Denial of Medicaid Step 6
    Wait to be contacted. If your state requires mediation before an appeals hearing is set, you will be contacted by a mediator or state Medicaid agent.[20]
    • You generally can expect to hear from someone within a month after you've filed your request for an appeal. You may receive a written notice, but more typically you'll be called, so make sure you've provided a good phone number where you can be reached.[21]
    • Some states don't have a formal mediation process, but you still will be contacted by an agent to discuss the reason for your appeal. If a settlement is possible, he or she will let you know.[22]
  2. Image titled Appeal a Denial of Medicaid Step 7
    Gather documents and evidence. You should prepare for your mediation the same way you would prepare for a full hearing, and be ready to prove your eligibility for Medicaid benefits.
    • Documents may include medical reports or anything else that demonstrates your medical need for the service or treatment for which Medicaid denied coverage.[23]
    • If you want the Medicaid agency to see any of the documents that support your claim, you can send them to the mediator who contacted you. He or she will forward them to the agent who will be representing the state agency at your mediation.[24]
    • Part of demonstrating medical need is explaining what will happen to you if you don't get the services you originally requested, and for which Medicaid denied coverage.[25]
  3. Image titled Appeal a Denial of Medicaid Step 8
    Request a copy of your case file. You have the right to view your entire case file before your mediation appointment.[26]
    • Your original denial notice should provide a name, address, and phone number you can use to request your case file. If not, you can contact someone at your local Medicaid agency to find out how to get this information.[27]
  4. Image titled Appeal a Denial of Medicaid Step 9
    Consider getting statements from witnesses. Your doctor may be best suited to provide a statement regarding the medical necessity of the treatment for which your benefits were denied.
    • Ask your doctor or other medical professional to provide a written statement explaining why the treatment was medically necessary.[28]
    • A doctor also can assist with a description of what might happen to you if you are denied the services you requested.[29]
  5. Image titled Appeal a Denial of Medicaid Step 10
    Determine your settlement range. Before mediation, you should have an idea in mind of the level of benefits for which you're willing to settle your claim.
    • Essentially, you need to know the minimum amount of Medicaid coverage that would enable you to meet your medical need.[30]
  6. Image titled Appeal a Denial of Medicaid Step 11
    Appear at the day and time scheduled. Mediations often are conducted over the phone using a conference call system.
    • Keep in mind mediation is a voluntary and confidential process. You won't be penalized if you don't arrive at a settlement, but if you do then your claim is resolved and you don't have to worry about a full hearing.[31]
  7. Image titled Appeal a Denial of Medicaid Step 12
    Evaluate any settlement offered. The mediator will work with you and the Medicaid agent to attempt to settle your claim.
    • If you believe the settlement offer won't meet your medical need, you don't have to take it. You still get your appeals hearing before a judge or hearing officer, and nothing discussed in mediation can be used against you at that hearing.[32]

Part 3
Attending Your Hearing

  1. Image titled Appeal a Denial of Medicaid Step 13
    Receive notice of your hearing date. If you are unable to reach settlement at mediation, your state Medicaid agency will send you written notice of the date, time, and location of your appeals hearing.[33]
    • Hearings must be conducted at a reasonable time, date, and place.[34]
    • Generally, your hearing must be scheduled within 55 days after you send in your request for appeal.[35]
    • If you won't be able to attend on your hearing date, you can ask for it to be postponed until a later date. However, you will have to show "good cause" for doing so, such as a scheduled medical procedure.[36]
  2. Image titled Appeal a Denial of Medicaid Step 14
    Prepare your documents and evidence. If you compiled evidence for your mediation, you can use much of this same evidence for your appeals hearing.
    • If you had a doctor or anyone else provide a statement or serve as a witness for your mediation, you should find out if they can testify at your hearing.[37]
    • Your evidence may include medical records, witness testimony, documents, or objects such as medical devices. The point of the evidence is to show the judge the type of medical treatment you need, its benefit to you, and the consequences to you if you don't get it.[38]
    • The testimony of your doctor can be especially helpful in explaining a procedure to the judge and why it is medically necessary for you.[39]
    • Make copies of any documents you plan to present, so that you have enough copies for yourself, the judge, the agency, and any witness who might be testifying.[40]
  3. Image titled Appeal a Denial of Medicaid Step 15
    Submit your evidence. You generally must submit your evidence to the Medicaid agency at least a week before your hearing is scheduled.[41]
    • Different states may have different deadlines, but generally you should expect to have your evidence to the agency and its legal representative at least a week before the date your hearing is scheduled.[42]
  4. Image titled Appeal a Denial of Medicaid Step 16
    Appear at your hearing. On the day and time of your hearing, you must be present or your appeal will be dismissed.[43]
    • Typically hearings are held over the phone, but you can request an in-person hearing.[44]
    • If you don't show up at your hearing, you can't have your appeal reopened unless you are able to show "good cause" for missing the hearing. This can be a difficult thing to prove and requires a far more serious reason than simply forgetting the date or losing your notice. As with justifying a late appeal request, you'd have to prove that you were too sick to appear or that some emergency kept you from being there.[45][46]
    • Hearing procedures differ among states. Your hearing may be over the phone, or you may have to go to the agency office or to the courthouse.[47]
    • Although the rules of evidence and procedure at Medicaid appeals hearings are somewhat relaxed compared to full court trials,[48] you still should observe similar standards of conduct. Address the judge as "your honor," and don't interrupt the judge or Medicaid agents while they are speaking.[49]
  5. Image titled Appeal a Denial of Medicaid Step 17
    Present your case. Explain to the judge or administrative officer the reasons you believe you are entitled to the benefits for which you applied.
    • You may find it helpful to make an outline before the hearing of the points you want to make to the judge. If you get off-track, you can refer back to your notes so you don't leave anything important out.[50]
    • The key to a successful Medicaid appeals hearing is providing enough information and evidence to demonstrate the medical need for the services or benefits for which you were denied Medicaid coverage.[51]
  6. Image titled Appeal a Denial of Medicaid Step 18
    Listen to the other side. If a Medicaid agent is present to oppose your appeal, he or she will explain the reasons your application was denied.
    • Take notes as the agency's representative and witnesses are speaking. You have the right to ask them questions after they've finished speaking.[52]
    • If an issue comes up that you think you can resolve by submitting additional evidence, you can ask the judge or hearing officer to postpone his or her decision until you've had an opportunity to provide that evidence.[53]
  7. Image titled Appeal a Denial of Medicaid Step 19
    Receive the judge's decision. After hearing both sides, the judge or administrative officer will enter a ruling on whether you are entitled to benefits, and the extent of the benefits for which you are eligible.
    • The judge may state his or her decision at the conclusion of the hearing, but regardless you'll receive a written notice. You should expect to receive a written notice of the judge's decision within 20 days of the date of the hearing.[54]
    • If the judge ruled against you, that notice will tell you how to file a second appeal.[55]
    • If you win your appeal, your Medicaid coverage will be retroactive from the date you first became eligible.[56]
    • In some cases, you may be ordered to complete another medical exam. If that happens, the state will pay the cost of the exam, but you must get any exams or tests done as soon as possible or your appeal will be denied.[57]

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