Medicaid: How To Appeal Denials

If your claim for Medicaid is denied, you have the right to appeal that decision.

The appeals process is very similar to the Social Security appeals, since they are part of the same legislation. However, each state handles its own appeals process. As part of the denial process, the state in which you live will tell you the procedure for making an appeal.

The purpose of the appeal is the same for each state even if the procedures are different: you want to provide Medicaid with enough new information or explain old information so that they will be justified in reversing their denial and granting you benefits.

In order to successfully change an approval into a denial, you need to know:

• The reason for the denial.
  • The reason for the denial should be spelled out in the letter of denial, but don't hesitate to contact the person with whom you've been working or who signed the letter if the reason is not clear. Try to find out precisely the reason for the denial - not that it was just "financial" or "medical." For example:
    • If the reason is financial (such as the Analyst thought your assets were too high for Medicaid eligibility), you need to know how high and how the number was arrived at before filing an appeal arguing about your income level. For more information about denials for financial reasons, click here.
    • If the reason is medical, that is they don't think you are disabled, find out which medical records were used to make that determination. Again, this should be in the denial letter, but you may have to contact the Analyst to find out. For more information abou denials for medical reasons, click here.
• Your rights of appeal.
  • Medicaid appeals are in two levels: Reconsideration is the first level of appeal. If you continue to be denied, you can then appeal to an Administrative Law Judge. If those levels do not provide the result you seek, you can take the case to state court. 
  • For information, see: Reconsideration and Administrative Law Judge. 

If not before, it is preferable to have an attorney do the appeal to an Administrative Law Judge.

For more information, see:

• Reason for Denial: Not Eligible Financially   
• Reason for Denial: Not Eligible Medically   
  
• The First Level of Appeal: Reconsideration  
  
• Administrative Law Judge  
  
• General Rules For When You Have Contact With An Insurer, Employer Or Government Agency
  

NOTE: In most states there are programs that will provide information about eligiblity, applying for, appeals, and living with Medicaid. There are even programs which supply people to attend hearings with you. Health insurance assistance program primiarily deal with Medicare, but they also deal with some aspects of Medicaid. You can locate a health insurance assistance program at: see: http://www.familiesusa.org/resources/program-locator/. If the agency doesn't have your answer, it can point you to an agency that does. You can also contact a legal expert to learn about special rules that may help in your situation. If the person charges for his or her services, the more homework you do before meeting, the less expensive your legal feels are likely to be.

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