Appealing a Denial of Medicaid Benefits & the Legal Process
If the Medicaid program in your state denies your claim, you can pursue an appeal if you feel that the denial was unjustified. The window for pursuing an appeal may be 90 days or less. Sometimes you will need to file an appeal within 10 days to continue receiving benefits. You may need to request an appeal in writing in some states, and it is a wise precaution to take even if it is not required. You should sign and date the appeal notice before submitting it in person to your local Medicaid office. To make sure that it is registered as received by the deadline, you should ask the person who receives the notice to make a copy and put a date stamp on it.
People who have received services from a managed care organization may be able to pursue a grievance process within that organization as well. This is not a substitute for a Medicaid appeal, however, so you should make sure to file your Medicaid appeal within the deadline. Sometimes a patient may lose their grievance proceeding in the managed care organization but prevail in a Medicaid appeal.
Getting Started on Your Appeal
Before submitting your appeal, you will want to review the notice of action that contains the explanation for your denial. It will contain the rules on which Medicaid based the denial, and it will tell you about the procedures for an appeal. Medicaid generally must send a denial notice to a consumer at least 10 days before taking action. You should keep the notice until the entire appeal process has been resolved.
While sometimes you can file an appeal after the deadline, you must have a good explanation for appealing late. Most late appeals are unsuccessful.
You may be able to get your appeal resolved in pre-hearing negotiations. Sometimes a Medicaid representative will contact a consumer after receiving their appeal notice. They may try to find out more about the basis for the appeal, and they may offer a settlement if they believe that your appeal has some merit.
Appeal Hearings
You have a right to review your file and the documents that form the basis of a Medicaid denial before the hearing. If you feel that you need more time to prepare or collect important evidence, you can ask for a postponement. The appeal hearing will be an administrative hearing conducted before an administrative judge or hearing officer. While the proceedings will be less formal than regular court, each side will have the opportunity to introduce witnesses to testify on their behalf. Each side also can cross-examine witnesses for the opposing side.
Many Medicaid applicants choose to handle these hearings on their own, but getting an attorney on your side can be helpful. An attorney will understand the procedural rules and know which strategies are most likely to prevail. You may be able to get low-cost representation for a Medicaid hearing through a local legal aid office.
Aid Paid Pending
If the notice of action involves a denial of a new service or treatment, you will not get this cost covered unless you win your appeal. By contrast, if the notice of action involves discontinuing or reducing a Medicaid benefit, you should be able to have your current benefits extend for the duration of the appeal process. Aid paid pending means that the benefits continue pending the outcome of the appeal. This often arises in situations involving someone whose income increases, potentially placing them above the Medicaid income limit.
The Medicaid program can take an adverse action against you within 10 days of sending you the notice of action. If you want aid paid pending, you will need to request a hearing within that time. The notice of action will provide the deadline for requesting aid paid pending in situations in which it applies.
In the event that a consumer loses their appeal, they may be required to pay back any Medicaid benefits that they received during the appeal process. These include the cost of any medical services that you received during that time, as well as any premiums that the state paid on your behalf.
