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Medicaid: How To Appeal Denials

Reason for Denial: Not Eligible Medically

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A denial due to not meeting Medicaid's standard for being totally disabled is the most common reason a claim is denied, but it can offer many opportunities for getting the denial reversed.

Disputing a claim by Medicaid that you are not disabled is going to take time, research and preparation. Whether or not, and exactly when, you were disabled enough to qualify for benefits is a very subjective issue despite Medicaid's attempts to make it objective. Your goal will be to use records that they haven't seen, and reinterpreting records they already have, to prove your point.

  • Check to see what medical records Medicaid used as a basis for their denying that your condition is severe enough to qualify for benefits.
  • The denial letter should list each doctor whose records the analyst used.
  • Check the list against your list of doctors you informed Medicaid about.
  • Get copies of the medical records each doctor filed, plus copies of any medical records that were not filed or were filed but which were not listed by Medicaid. Your objective is to find medical records that Medicaid has not seen.
  • Note that all of your medical problems do not have to come from the same condition. For example, if you are dealing with a physical disease, also consider submitting records from your therapist treating you for depression.
  • If the question is the onset date of your disability, go through the medical records to show that you had the same symptoms at the earlier time as you did at the time Medicaid used to declare you disabled.

When appealing denials of treatment or of treatment procedures, your physician's assistance is vital.

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