Appealing a Medicaid Denial

Although Medicaid is a public health insurance program that typically covers certain classes of uninsured, lower income, and disabled persons, you still have certain rights in terms of coverage, denials, and appeals of your claims, just as if you were covered by a private insurance plan. If you file a claim with Medicaid for coverage of a medical procedure, medical equipment, or other healthcare service, and Medicaid denies coverage of your claim, you have the right to appeal the denial of your claim. While Medicaid laws and procedures differ based on your state’s law, there are some common principles that govern Medicaid claims in any state, and federal regulations that govern state Medicaid laws. By following some simple steps to appeal the denial of your claim, you can ask Medicaid to reconsider its decision about your coverage for a product or service.

Appealing Medicaid Denials

When a claim is submitted for Medicaid coverage, your state Medicaid agency must give you prompt notice, in writing, as to whether your claim has been accepted or denied, in full or in part. Once you receive this notice, you typically have a limited amount of time in which to appeal the decision, or to ask your state Medicaid agency to reconsider its decision about your claim.

Administrative Hearings and Procedures

Every state has relatively extensive administrative appeal processes that may include agency reconsideration and administrative hearings. In these purely administrative proceedings, the formal rules of evidence and court procedure do not apply. Therefore, it is possible to navigate through these administrative processes without the assistance of a lawyer, either on your own, or with the help of an advocate.

Getting Appeals Help

As a practical matter, though, it may be wise to retain an experienced Medicaid attorney to assist you with your appeal, even during the administrative proceedings. Resolving the denial of a Medicaid claim at the administrative level is less costly than resolving it through often-lengthy court proceedings, and an attorney may be better equipped to present your case in the best light possible before agency officials.

When to Seek Legal Help

It is not until your administrative remedies for the denial of your Medicaid claim have been exhausted that you are eligible to seek any recourse from the court system. If you attempt to resolve the denial of your Medicaid claim in court before exhausting your administrative remedies, then your court claim will be dismissed for lack of jurisdiction.

However, once you have exhausted your administrative remedies, your only remaining remedy lies with the court system.

Eligibility to Appeal or File a Complain

Typically, you are eligible to file a complaint in court asking that the denial of your Medicaid be overturned. Unlike administrative proceedings, the formal rules of court, evidence, and trial procedure apply to these court proceedings. At this level of appeal, an attorney may be essential to your ability to maintain your lawsuit with any chance of success. Therefore, if you have reached a stage in the Medicaid appeals process where the next step is to file a lawsuit in court, you should contact an experienced Medicaid attorney for assistance in evaluating and pursuing your claim.

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