The Medicaid Appeals Process
In July of 2017, there were new federal regulations about how to appeal a benefits decision. After talking with your provider directly, there are certain actions you can take to try and resolve your issue.
Steps to Take in Your Appeal
- Submission. You must file an appeal of an adverse benefit determination within 60 days of receiving the decision. Under most circumstances, your plan must resolve the issue within 30 days. However, you may be eligible to file an expedited appeal if you are at risk of serious physical injury, such as loss of life, limb, or bodily function.
- File a grievance. Every California Medicaid plan must have a grievance system. You can file a grievance or complaint if you disagree with your plan’s terms or a health care decision.
- Request a Medi-Cal fair hearing. If you have a grievance against your plan provider, you can request a Medi-Cal fair hearing. During a hearing, an Administrative Law Judge will hear your claim. They may or may not be able to issue a determination. Hearings are time-sensitive and must typically be requested within 90 days.
Contact a California Medicaid Appeals Attorney Today
While Medicaid appeals may seem straightforward, they are often grounded in obscure bureaucracy. Depending on the circumstances of your claim, you may have options beyond simply waiting for the state or your care provider to issue a determination. An experienced California Medicaid claims attorney can help you receive the compensation you need and the benefits you deserve.
