How to Appeal a Denial of Medicaid Services
Table of Contents
It is common for people to represent themselves when they appeal a denial of Medicaid services. You are not required to have an attorney. This document provides you with an overview of the Medicaid appeal process with step-by-step instructions for how to represent yourself during a mediation and at a hearing. The mediation and hearing process is what you use to argue that the decision regarding your request for services be reversed.
The right to appeal a denial of Medicaid services
When you request a new Medicaid service or a continuation of services you already receive, you will get a letter from an organization such as Computer Services Corporation (CSC)* or Carolinas Center for Medical Excellence (CCME).1 This letter either:
- Approves your request for a service;
- Denies your request for a service, durable medical equipment, assistive technology, or medication; or
- Denies your request, but approves a lesser level of service than you requested.
Your provider will also get a copy of this notice. The notice must be mailed to you on the same day as the decision.
You have the right to appeal decisions to deny, terminate, suspend, or reduced the Medicaid-funded service or equipment that you requested. Your notice is required to include instructions on how to appeal the decision, and contain the following information:
- The name of the person whose services are denied or changed by the decision;
- Which service was denied and why;
- When the service will end or change;
- What you need to do to appeal the decision;
- A statement that your service cannot end or change until the appeal is resolved as long as you ask for an appeal before the service is supposed to end or change;
- How to get in touch with DHHS for more information about why the service you asked for was denied or changed;
- Contact information for Legal Aid of North Carolina or other legal services groups; &
- A Hearing Request Form. (You can also call the Medicaid Contact Center at 888-245-0179 if you need an additional copy of this form.)
The only exception to this right to appeal is if there is a state-wide policy change, which may apply in limited circumstances. In such circumstances you may be able to request an exception or modification to the policy and appeal that adverse agency decision.
An overview of the appeal process
Medicaid appeals allow you to appeal an unfavorable decision with or without an attorney. Although an attorney can be helpful, people are often successful in Medicaid appeals on their own or with the help of a relative or friend.
Keys to a successful appeal of denial of Medicaid services:
- Know your rights
- Be organized
- Present information to the Administrative Law Judge that shows your medical need for the services you are requesting.
In North Carolina, you will have an opportunity to discuss your request for services through mediation before you get to a hearing. Mediation is an informal process in which both parties are guided through a discussion by a neutral, third-party mediator to see if they can reach an agreement. This is also your opportunity to learn more about what concerns Medicaid has about your request. You can use this information to help you prepare if the case continues on to a hearing.
If mediation does not resolve the issue, the next step of the process is a hearing at the NC Office of Administrative Hearings (OAH) before an Administrative Law Judge. At the hearing you will have the chance to present evidence.
Evidence can include:
- Supporting documents.
- Your testimony.
- Having someone testify on your behalf.
- Making arguments to the Judge.
Who can help me with the appeal process?
- Anyone you trust, such as a friend or relative can help you during your appeal.
- Your provider of the Medicaid service that was denied. For example, your doctor’s office may be able to address the concerns directly by re-writing the request or submitting additional paperwork.
- You can also contact Legal Aid of North Carolina at 1-866-219-5262 to see if you can get legal assistance. Visit their website for more information.
How to request an individual hearing and appeal your denial of Medicaid services
Step #1: File the Hearing Request Form
The Hearing Request Form is enclosed with the letter informing you of your denial. If you did not get a Hearing Request Form at the same time as the notice denying your services, contact DHB immediately at 888-245-0179 to request a Hearing Request Form.
Instructions on how to file this form are on the form itself. The form must be returned by mail or by fax to OAH (Office of Administrative Hearing) and NC DHHS to appeal the denial of your request for services. The mailing addresses and fax numbers will be listed on the notice you received in the mail. Faxing is generally the easiest way to send the appeal to both OAH and NC DHHS.
Important things to remember
Keep proof that you mailed or faxed the Hearing Request Form.
- In order to appeal your denial of services, the Hearing Request Form must be submitted to OAH within 30 days from the date on the denial letter or you generally lose your right to appeal.
Step #2: Preparing for mediation
Within 25 days of filing your appeal, a mediator will contact you to schedule a time to discuss your denial of the Medicaid service with a representative from the NC DHHS, DHB. This meeting is called a mediation, and it will likely take place over the telephone.
Who is involved in mediation?
If you are not represented by an attorney, the parties at the mediation will be a neutral, third-party mediator, yourself, and a representative from the organization DHB contracted to review your request (i.e., CCME, CSC, etc.).
- Your doctor, nurse, aide, provider, case manager, or family member can participate in the mediation to explain your need for the services.
If you are represented by an attorney, an Assistant Attorney General representing DHB will also participate in the mediation. You should let the mediator know that you are represented by an attorney as soon as possible.
Maintaining your services during an appeal
If you file your Hearing Request Form within 10 days from the date on the letter, there will be no break in your services, and your services will continue at the level you were receiving prior to your denial until a final decision is made at mediation or a hearing.
If you file your Hearing Request Form after 10 days, but before 30 days, you may have a break in services for a short period of time until your appeal is received by OAH and services are reinstated.
The letter you received states that you may be required to pay for services that continue because of your appeal. While this is possible if you ultimately lose at a hearing, it does not generally occur.
Voluntarily discontinuing services to avoid having to reimburse DHB may be a bad strategy. If you can live without services while you are appealing the decision, the judge may think you do not need the appealed services.
Organize any information or records you have documenting your medical need for the service requested.
You are entitled to see the information that was used when the decision was made to deny your request for a service. You can request a copy of your DHB case file by contacting the Assistant Attorney General assigned to your case in the NC Department of Justice, Division of Health and Public Assistance at 919-716-6855. Have your case number ready when you call.
If you have documents, such as a letter from your doctor, that you would like the State or its agent to see before mediation that will facilitate your discussion, give a copy directly to the mediator. The mediator will give it to the State’s representative.
Medical professionals, including your doctor, serve as the best witnesses regarding your medical need for the service requested. A medical professional can provide a letter or affidavit (an affidavit is a notarized, signed statement) explaining why you have a medical need for services.
Clinical coverage policy
Clinical coverage policies describe the criteria and factors evaluated in approving or denying requests for services. You should be familiar with the clinical coverage policy that governs the service you requested. You can get clinical coverage policies on the DHB website, or by calling DHB at 1-800-662-7030 or 919-855-4100.
Have a compromise number of hours in mind
Be ready to explain what would happen if you do not get the service you requested. Sometimes CCM will offer you more hours than were originally approved, but still less than what you requested. This is called a settlement offer. Figure out the minimum number of hours of the service that are necessary to meet your medical need. If you are willing to settle for a lesser number of hours than requested, you may be able to resolve the case at mediation and avoid a hearing.
Step #3: Attend the mediation
Mediation is a voluntary and confidential process. There is no penalty if you do not arrive at a settlement during mediation. There are advantages to mediation. You might be able to settle the issue without having to go through a hearing at OAH. You often learn more about the reasoning behind the decision to terminate services, which will better prepare you to defend your position at the hearing if you don’t reach a settlement. There is nothing to lose at mediation.
If you agree to participate in mediation, make sure that you attend. If you fail to appear without good cause, your appeal will be dismissed.
What happens if you do not settle at mediation?
If you do not settle at mediation, you simply go on to a hearing at OAH. You can use the information you gather during mediation to make better arguments during the hearing. However, settlement offers / rejections that you discussed at mediation are confidential, and cannot be disclosed at the hearing.
If the settlement offer meets your medical need without putting your health and safety at risk, you may decide to accept the offer and settle your appeal. The offer may not be available later at the hearing.
If you feel the settlement does not meet your medical need, you can choose not to take it. There is no penalty for saying “no” to a settlement offer at mediation. You will move on to the next step, which is an evidentiary hearing at OAH.
Administrative hearing at the Office of Administrative Hearings (OAH)
Step #4: Preparing for the Hearing
When is the hearing?
OAH is supposed to hear your case no more than 55 days after you send in your Hearing Request Form. If you participated in mediation, this time is counted as part of those 55 days. If mediation is not successful, your hearing will be scheduled very shortly after mediation. It is a good idea to being preparing for a hearing as soon as you send in the Hearing Request Form. You will receive written notice of your hearing date by certified mail.
Please note that the current Medicaid Administrative Law Judge’s procedure is to schedule a “soft” hearing before scheduling the actual hearing where you present your evidence. This “soft” hearing is really just an informal settlement conference and gives the parties another opportunity to settle the matter before the full hearing. If the parties can’t work it out at this point, the judge will ask them to confer and agree on a hearing date. We recommend you call OAH and speak to the Judge’s law clerk to confirm that this is a “soft” hearing and you will not be required to proceed with the actual hearing at that time. The current clerk is Anne Hollowell. You can email her at firstname.lastname@example.org or call her at (984) 236-1933
If you need more time before your hearing, you can ask the judge for a “continuance” (later court date). You must show “good cause” for why you need a continuance. Examples of good cause include scheduled medical procedures or needing additional time to review documents. To get a continuance, you must write a letter to the judge and send a copy to the Assistant Attorney General assigned to your case.
Where will the hearing be held?
Most hearings take place by phone. However, you can request an in-person hearing. If you request an in-person hearing, it will be in Raleigh, unless you request otherwise. You can request the hearing be in your county of residence if you can show “good cause,” such as that your disability prevents you from traveling to Raleigh. If you have an in-person hearing outside of Raleigh, then all of your witnesses may have to appear in-person.
What do I have to prove?
You must show the judge that the:
- Service you requested is medically necessary, and
- That the Department made a mistake denying or modifying your Medicaid services.
Proving your case
You may present evidence to help you prove to the judge that the service or equipment you asked for is medically necessary and that your request should not have been denied. Your “evidence” can include witness testimony, records, documents, videos, etc. Your evidence should help the judge understand these things:
- The type of service you need.
- The number of hours you need.
- How the service has or will help you.
- What will happen (the consequences) if you don’t get the service.
Types of evidence you can consider using to support your case
Your doctor, nurse, aide, CAP worker, family members, and anyone else who can testify to your medical need for services can be a witness.
It is helpful to have your treating medical professional testify. The medical professional should be prepared to describe the service requested and testify specifically as to how it helps you. They should also state the number of hours required, and the consequences for you without the service or level of service requested. Instead of testifying, the provider can also write a letter that explains your need for the services.
It is also helpful to have your services provider at the hearing to tell the judge why the Medicaid services you asked for are medically necessary. For instance, they could explain if your Medicaid services have helped you get better or learn new things, or if you would deteriorate without the services.
Witnesses can testify by phone if they are not available to attend the hearing in person.
You should check your witnesses’ schedules to make sure they are available on the date of your hearing. If they are not, this may be good cause for requesting a continuance (later court date) from OAH.
This includes medical records, school records, or any other records that help the judge understand why the service or equipment is needed.
This could be a letter from your doctor, a description of the service or equipment you are asking for, or anything else that is written down.
For example, if you requested a type of equipment, you could show the judge an example (like a picture) of the equipment you asked for.
You must submit your evidence to OAH and the Assistant Attorney General assigned to your case at least 5 business days prior to the hearing. Be sure to include the case number that OAH provides to you on all correspondence.
You are allowed to bring evidence with you to the hearing that you did not submit to OAH and DHB in advance. However, if you do so, DHB may ask the judge to continue (postpone) the hearing for 15 days to give them time to look at your new evidence.
Step #5: The hearing
The hearing is an opportunity for both sides to present evidence and witnesses to explain why you do or do not qualify for the service you requested.
Who is involved at the hearing?
You can find out which Assistant Attorney General is assigned to represent DHB in your appeal by calling the NC Department of Justice, Division of Health and Public Assistance at (919) 716-6855.
If you do not have an attorney, the judge must make a reasonable effort to give you a fair hearing. This means that the judge does not expect you to know the law as well as an attorney. He or she should be as helpful as possible during the hearing. Very few people have attorneys for Medicaid appeals.
While you are in the courtroom, you should follow certain rules.
- Address the judge as “your honor” or “judge”.
- Address the attorney representing DHB as “Mr.” or “Ms.” and their last name.
- Do not accuse DHB witnesses of lying; however, you can point out evidence that contradicts a witness’s testimony.
- Stand up when you are talking to the judge, and ask the judge’s permission when you need to move around (such as approaching a witness). If you are not able to stand up during the hearing, you can inform the judge and ask if you may remain seated. You can also ask the judge for any other assistance you may need, such as help getting documents to the judge and witnesses.
Step #6: After the hearing
The Administrative Law Judge will issue a decision in your case within 20 days of the hearing, either agreeing or disagreeing with DHB’s decision to reduce or terminate services.
How does the judge make his or her decision regarding your appeal?
The law says that the judge has to decide whether DHB:
- “Acted erroneously;”
- “Acted arbitrarily or capriciously;”
- “Failed to use proper procedure;”
- “Failed to act (as required by law or rule);” or
- “Exceeded its authority or jurisdiction.”
Simply put, this means that the judge has to decide if DHB did something wrong when they denied or changed your service, if DHB had a good reason for its decision, and if DHB followed all the laws when it made its decision.
Final agency decision
The ALJ makes the final agency decision for OAH cases. If you disagree with the ALJ’s decision, you may appeal to the North Carolina Superior Court within 30 days by filing a Petition for Judicial Review in the county court where you reside. At this point, we suggest that you seek the assistance of an attorney in appealing the ALJ’s decision, though it is not required.
The petition should state why you do not agree with the decision, what has happened in your case up to this point, and what you want the Superior Court to do for you. All appeals are heard by a Superior Court judge, without a jury.
To file your petition in Superior Court, you may have to pay a filing fee. If you cannot afford this fee, you can file a form to request that the filing fee be waived. This, and other required papers that must be filed, such as a “Civil Action Cover Sheet,” can be obtained at your local courthouse or online at under forms.
You must send a copy of your petition to all parties listed in the final agency decision, and the registered agent for the NC DHHS within 10 days after you file the petition. You can send the petition to the parties either by personal delivery or by U.S. mail.
In the Superior Court hearing, you are bound by the evidence shown to the judge at the administrative hearing, unless:
- The Superior Court judge says that more evidence is needed, and
- You could not reasonably have shown the evidence to the judge at the administrative hearing.
Here is a list of attorneys and organizations that may be able to help if you decide to appeal to the Superior Court.
1. Computer Services Corporation (CSC) and the Carolinas Center for Medical Excellence (CCME) are among some of the organizations contracted by the state to review requests for Medicaid services or equipment. The North Carolina Department of Health and Human Services (DHHS), Division of Health Benefits (DHB) is the State agency in charge of the Medicaid program.