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Medicaid: How To Appeal Denials

The First Level of Appeal: Reconsideration

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Generally, you have sixty days from the letter of denial to restate your case in writing to Medicaid.

Reconsideration is exactly what it says: it is a request that Medicaid reconsider the denial of your claim and, hopefully, reverse their position and approve the claim.

To get Medicaid to change an opinion, you must give Medicaid something that provides a reason to make a change. Unless you can explain information Medicaid already has in a new light, or provide information Medicaid doesn't already have, the denial is not likely to be reversed.

  • To start the appeals process, you must follow the appeals instructions that are included in your denial letter.
    • Forms to request a Reconsideration of your claim will probably accompany the denial letter.
    • If not, you may get them from where you first applied for Medicaid.
  • If you had extensive medical problems between the initial application and the Reconsideration:
    • While the records of your newer situation will certainly help gain an approval that you are now disabled, Medicaid may establish an onset date that is much later than the one for which you originally applied.
    • If it is your goal to both get approved for Medicaid and have the onset back when you first applied, include more records from the earlier period so Medicaid will be able to see that your disability goes back that far.
  • Submit a letter from your doctor.
    • Show your doctor the denial letter and review the medical records together after you've had a chance to review them.
    • Point out where you think the documentation of your symptoms is weak, and point out items you may have reported to your doctor that didn't make it into the record. Ask your doctor to write a letter identifying from a medical point of view his or her opinion of your ability to work and exactly what keeps you from working.
  • Submit third party testimony.
    • Especially if you didn't submit any with your initial application, obtain letters from people you work with as well as people you live with or to whom you are close.
    • Ask them to write their observations of any changes in you. Ask them to be specific and to pinpoint dates as much as they recall. For samples, see Social Security Disability Insurance (SSDI).
  • Submit other evidence.
    • A great source of other supporting evidence can be work or school records which sometimes contain a wealth of information about job performance and psychological testing.
    • Any records that were generated before applying for Medicaid benefits will be given greater weight than those which are generated afterward.
  • Take your time completing the form: Request For Reconsideration. This form along with any documentation you submit with it becomes your appeal, so it is important that you complete it carefully and thoroughly.

When you review the form you will see that most of such requests are pretty self-explanatory, even though they vary from state to state.

Generally, the heart of the form and the key to your success in overturning a denial is the section that says something to the effect that: "I do not agree with the determination made on the above claim and request reconsideration. My reasons are:"

Here is where you want to present your argument and the facts that support it. See the particular section above that applies to you for advice on what should be completed.

List every argument that is in your favor. If you have one strong reason and two weaker ones, list them all even if you're convinced the strong argument alone will get your claim approved. Some claims examiners and Administrative Law Judges will not allow you to present any new evidence that isn't in your request for appeal so you want to include everything you can think of. Also bear in mind that while one argument may be persuasive to you, it may be another argument that is persuasive to the person who will review your case.

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