How to File an Appeal with the State

Asking for a State Medicaid Fair Hearing

When you file an appeal with the State you are asking for a Medicaid Fair Hearing.

A fair hearing is a review and discussion of your case. It is not a court of law. A hearing officer (someone not involved in your case) will listen to your complaint, explain the rules to you and answer your questions. The hearing officer will make a final decision about your complaint and will send you the decision in writing.

You have the right to ask for a Medicaid fair hearing when:

1. You are told you don't qualify for Medicaid services.
2. You apply for services and your request is not acted upon promptly.
3. You are told that your services have been reduced.
4. You are told that your services have been suspended or stopped.

Here are some examples of when you might request a fair hearing:

• You get a letter that says you are not eligible for Medicaid.
• You or your doctor gets a letter denying a prior authorized service.
• You get a letter that says a service was denied because it is not "medically necessary" but you or your doctor thinks you need the service.

You should always receive a letter, which explains why your services were denied, reduced or suspended. The letter must have information about how to request a Medicaid fair hearing. If you are told over the phone that a service is denied, reduced or suspended ask the person to send you the decision in writing.

You, or someone you ask to help you, can ask for an appeal by calling the:
Medicaid Hotline at 1-800-252-8263

If the complaint is about Long Term Care services then you should call the:
STARLine at 1-800-411-9929.

• You will have 90 days from the date on the notification letter from your health plan to request a Fair Hearing. If you do not request a hearing within 90 days, you will lose your right to a hearing.
• You can file a request for a Medicaid fair hearing process at any time. You can file an appeal with your health plan and the state at the same time. You do not have to wait until your health plan makes a final decision before you file an appeal with the state.
• The State has 90 days from the date of your request to conduct the hearing and send you written notification of the decision.
• The decision of the hearing officer will be final. The hearing officer will send you the decision in writing. The hearing officer may agree with the original decision or he/she may overturn the decision.
• You do not have a right to a Fair Hearing if the services you requested are not a covered Medicaid service.

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