Medicaid Managed Care Organization Denials

Yes! The law requires the managed care organization to provide a written notice explaining what was denied and why. Some common targets of Medicaid denials are wheelchairs, safety beds, standers, and home and community-based services.

• You must file the appeal within 60 days of the date stated on the managed care organization’s denial notice. If the denial is about home and community-based waiver services and you would like to request continuing benefits, you must file the appeal within 10 days of the date on the notice OR before the date the change takes effect, whichever is later.
• When you file the appeal, include all information you think would be helpful for your managed care organization to know about your need for the specific services or equipment. You can include pictures and medical records or letters from your health care providers.
• How to file your appeal and where to send it (by mail, email, or fax) will be included in your notice.
• It is very important that you keep a copy of your appeal and any records or additional information you sent with it.

Your case manager should be able to provide basic advice and guidance regarding the MCO’s appeal process.

The managed care organization will send you an acknowledgement letter, confirming it received your appeal. The MCO must review the appeal and send you a decision in the mail within 30 days of receiving the appeal.

• Yes! If the managed care organization still denies your request for services, you have the right to ask for a hearing before an administrative law judge. Information on how to ask for a hearing should be included with the appeal decision letter.
• You must request a hearing within 120 days of receiving the appeal denial.
• If you are granted a hearing, you will receive information in the mail about the hearing process and next steps.