Medicaid Appeals

Every state’s Medicaid program is different, but each state must follow a base set of federal Medicaid rules for appeals of medical decisions, including fair hearings when services have been denied, whether during the prior authorization process of after services have been rendered.  

Per federal rules when a Medicaid denial is issued, the notice must include the following information:

  • a clear & understandable statement of the proposed action and the reasons for it
  • an explanation of your right to, and how to get a county conference and a state hearing
  • an explanation of how you can get a “stay put” on your services by timely asking for a hearing
  • the applicable regulations
  • a telephone number to call about free legal services

If you were denied a new service or treatment, the benefit won't be paid for until you receive an approval. For instance, a recipient who gets a notice that Medicaid will not pay for a transplant will not be entitled to "aid paid pending" and will need to win his appeal before he can get the transplant.

Seek a Fair Hearing Right Away

You and your patient should seek a State Fair Hearing as soon as you have any issue with a Medicaid request or denials of services. Often it takes a few weeks to a month to have the Fair Hearing. No matter what, the State must provide a Fair Hearing and make its decision within 90 days of the date you asked for a hearing. Learn more about the Fair Hearing Process (Community Health Advocates.org).

If the patient is in urgent need of transplant, and can't wait the standard 90 days for a Fair Hearing, he/she should ask for an expedited Fair Hearing. The State Fair Hearing Agency should be able to schedule an expedited Fair Hearing right away. 

File an Appeal with the Plan

You should also file an appeal with the plan as soon as you receive a denial. 

The plan must reconsider its decision if they did not talk with the doctor who is asking for the transplant for your patient.  If you feel a decision was made without discussing the case with your patient’s physician, you have the right to ask for a reconsideration, and a new decision must be made within one business day.

Tips for Medicaid Appeals

  • Appeal by the deadline
    When you receive a denial, the denial notification must tell you how to file an appeal. When looking at the instructions on how to appeal, the appeal deadline is one of the most important pieces of information on your appeal notice. You must request your appeal within the deadline, or you will be required to justify a late appeal. States have different deadlines, but the deadline will be no more than 90 days from the date the denial notice was mailed (and may be less).
  • Appeal to the plan and the state
    Many times you can file your appeal with your plan first, but you should also file an appeal with your state Medicaid agency before your appeal deadline runs out. If the appeal with the health plan is upheld, you want to still be able to appeal to the state.
  • Follow the appeal format requested by the state
    Some states require that you request your appeal in writing, while in some states you can request an appeal orally.
  • Submit a written statement of patient authorization
    If you file an appeal on behalf of a patient, make sure to submit a written statement, signed by the patient, their parent if under age, or guardian if one is assigned, telling the Bureau of State Hearings that you have been given authority to represent your patient. Learn more and understand when this may not apply (Disability Rights Ohio website).

  • Provide comprehensive supporting data
    Always submit as much information to support your position as you can. The fastest way to get a decision is to submit all necessary information the first time.