Appealing a Medicaid Denial for a Service or Treatment

If you receive a notice of action that you’re being denied Medicaid, you can appeal. Here's how.

By Elizabeth Dickey , J.D. University of Virginia School of Law
Updated by Bethany K. Laurence , Attorney UC Law San Francisco

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If you're a Medicaid recipient and your state Medicaid agency or managed care organization won't approve payment for a medical treatment, you have the right to appeal the denial. Every state's Medicaid program is different, but each state is required to follow federal Medicaid rules—including those about fair hearings for Medicaid recipients denied services. (If you were applying for Medicaid coverage for the first time and were denied, see Nolo's article on appealing a denial of Medicaid for ineligibility.) In this article, we'll discuss why Medicaid denies some claims, your right to appeal a Medicaid denial, and how you might get Medicaid to continue paying for medical care during your appeal.

• What Types of Claims Does Medicaid Commonly Deny?
• Reading Your Medicaid Denial Notice of Action
• How to Appeal a Denial of Medicaid Treatment or Services
• Aid Paid Pending: Keeping Medicaid While You Appeal
• Negotiating Your Medicaid Appeal Before a Hearing
• Preparing for Your Medicaid Appeal Hearing

What Types of Claims Does Medicaid Commonly Deny?

Medicaid can deny services for various reasons. Sometimes, it's a simple billing error—your health care provider used the wrong code or billed related services separately instead of bundling them under one code. Medicaid can also deny a claim if you see a provider or try to fill a prescription not covered by your state or managed care plan.

State Medicaid programs are permitted to implement cost-saving measures. So, Medicaid won't pay for treatment that isn't considered "medically necessary." And each state can define medical necessity for its Medicaid program and base its claims approval on that definition and the state's utilization control (money-saving) procedures. (42 CFR 440.230(d).)

So, although federal law requires states to cover things like children's immunizations and prenatal care and delivery, some medical care is optional, and what's covered varies from state to state. Most state Medicaid programs will typically deny claims for elective procedures, including services and treatments, such as:

• cosmetic orthodontia, including braces and orthodontic aligners (invisible braces)
• adult dental services (in some states)
• cosmetic surgeries and procedures, like rhinoplasty or liposuction (not to be confused with reconstructive procedures following an accident or illness, which are generally approved)
• non-medical weight loss procedures, like:
  • dietary counseling
  • personal trainers
  • gym memberships, and
  • weight loss groups and apps
  • sleep apnea
  • high blood pressure
  • high cholesterol, or
  • diabetes

  Even in states with broad Medicaid coverage, claims are sometimes denied due to utilization controls. Those can include quantity limits (on the number of therapy sessions or medications) or requirements to try the cheapest treatment possible first.

  Reading Your Medicaid Denial Notice of Action

  Your state Medicaid agency must give you a written notice (called a notice of action) when it denies a service or treatment that you or your doctor requested. The written notice must explain all of the following:

  • what action the agency is going to take
  • the reasons for the action, including the specific rules the agency is relying on
  • how to appeal the denial, and
  • your deadline for filing an appeal.

  If you receive Medicaid benefits through a managed care organization (like a private insurance company), your denial notice must also explain how to appeal the denial of service within the managed care organization.

  Except in a few unusual situations, federal rules require state Medicaid agencies to mail denial notices at least 10 days before taking action. And if you don't speak English, you can request to receive the denial and appeals information in your native language.

  The appeal deadline is one of the most critical pieces of information on your appeal notice. You must request your appeal within the deadline, or you'll have to justify a late appeal with a good reason.

  Each state sets its own appeal deadlines. The deadline can't be more than 90 days from the date the denial notice was mailed, but it can be less. To continue to receive benefits, you might only have 10 days to file the appeal (more on this below).

  Read your notice carefully and keep it until your appeal is over. It should contain information that will help you appeal the Medicaid denial.

  How to Appeal a Denial of Medicaid Treatment or Services

  Some states require that Medicaid recipients request an appeal in writing, and others allow you to request an appeal verbally (by speaking with someone). Even if you're not required to make a written appeal request, it's a good idea to put it in writing.

  How to Write a Medicaid Appeal Notice

  Your Medicaid appeal request need only be a simple written statement, such as: "I want to appeal the denial notice dated 3/1/24." Be sure to sign and date your appeal notice before submitting it.

  If possible, submit your written appeal request in person at your local state Medicaid agency office. Ask the person who takes your appeal notice to make you a copy and put a date stamp on it to show that it was received by the deadline. You want to avoid having to prove later that you submitted your appeal on time or having to justify a late appeal.

  Handling a Denial From a Managed Care Organization

  If your denial notice comes from a managed care organization, it should include information about filing a grievance within the organization. Follow the instructions to file an appeal and try to win your case using the organization's own internal process.

  If your claim is still denied after an internal appeal, you might be able to request an external review by an independent review organization. Your managed care provider must abide by the outcome of an external review. (Contact your state's consumer assistance program to find out if your claim qualifies for external review.)

  Even if you're filing an internal appeal with a managed care organization, you should still file an appeal with your state Medicaid agency before the deadline. That way, if you're unsuccessful in your grievance with the managed care organization, you've preserved your right to appeal directly to your state Medicaid office.

  The good news is that Medicaid appeals are relatively fast (unlike Social Security appeals, which can take years). For example, if you're appealing a denial for urgent care, your state or managed care plan must give you its decision within 72 hours of receiving your appeal request.

  For appeals regarding non-urgent care that you haven't already received, you must get a decision within 30 days. And if you've already received the medical service and payment was denied, it can take up to 60 days to receive a decision.

  Aid Paid Pending: Keeping Medicaid While You Appeal

  You should look carefully at your notice to see if you're entitled to "aid paid pending." Not everyone is eligible, but if you are, you might be able to have your Medicaid benefits continue while you wait for the outcome of your appeal.

  If you were denied a new service or treatment, Medicaid won't pay for it until you win your appeal. For instance, if you received a denial notice saying Medicaid won't pay for your gastric bypass surgery, you won't be entitled to aid paid pending and will need to win your appeal before you get the surgery.

  But the rules are different for Medicaid benefits you're already receiving (like ongoing physical therapy). If you get a notice saying your coverage for the benefit will be reduced or cut off, you can usually ask that the current benefit continue for as long as the appeal process takes.

  For example, let's say you get a notice that you'll lose your Medicaid benefits because the agency thinks you're "over-income" (earning too much money). You'd be entitled to request that the "aid" be "paid" pending the outcome of your appeal.

  Federal Medicaid guidelines require Medicaid recipients who want aid paid pending to request a hearing before the date the agency intends to take action (before your benefits are cut). That means you'll need to submit your appeal notice quickly because Medicaid can take the action to stop your benefits in as few as 10 days after sending you the notice. Your notice should state whether you're eligible for aid paid pending and the deadline to request it.

  If you received aid paid pending but you lose your appeal, the Medicaid agency might ask you to repay the cost of providing benefits during your appeal. Keep in mind that the cost of providing Medicaid benefits includes:

  • the cost of medical services you receive during the aid paid pending period, and
  • the monthly premium cost to keep you enrolled in your state Medicaid program.

  Negotiating Your Medicaid Appeal Before a Hearing

  Many Medicaid appeals are settled in the pre-hearing stage, so you might not need to have a hearing to win your appeal. After you submit your appeal request, an agency representative might contact you to ask the reason for your appeal. If a settlement is possible, the representative will discuss that with you.

  Preparing for Your Medicaid Appeal Hearing

  If your Medicaid appeal goes forward to an administrative hearing, the state must tell you how the hearing will be conducted. Under federal Medicaid rules, your state must allow you to review your Medicaid files before the hearing. That includes all the documents the state agency relied on to decide to deny service or treatment.

  It's generally a good idea to review your file. As you do, write down the main points you want to make to the judge or hearing officer so you don't forget them during the hearing.

  You also have the right to have your own witness testify at the hearing and to cross-examine any of the state's witnesses. If an issue comes up during the hearing that you think would be resolved if you submitted additional evidence to the judge, ask the judge to delay making a decision and give you more time to get the information.

  You can represent yourself at a Medicaid hearing, but you might want to find an attorney to represent you. While most Medicaid denial hearings have relaxed rules of evidence, they're still legal proceedings with witness testimony and cross-examinations. You can contact your local legal aid office to find out if a lawyer is available to represent you in a Medicaid appeal. Federal Medicaid rules also allow you to use a relative, friend, or any other spokesperson you choose to help you with your appeal, but your chance of winning increases if you hire a Medicaid lawyer.