Medicaid is a lifeline for millions of Californians. However, filing a Medicaid claim can be complicated. Even if you have a compelling claim with strong evidence, success is never a guaranteed outcome. Officials do not always approve treatments, including treatments for life-threatening conditions.

However, an adverse determination is not a final decision. An experienced California Medicaid claims attorney could help you file an appeal, asserting your right to high-quality medical care. Appealing a Medicaid claim decision

Reasons to Appeal a Medicaid Determination

A Medicaid claim denial is not always final. If you believe the state has erred in issuing a decision, you have the right to file an appeal.

When to Appeal a California Medicaid Decision

  • You have been denied benefits for a health care service, product, or medication that you believe Medicaid should cover  
  • You have been denied reimbursement for out-of-pocket medical expenses
  • You need to change or renegotiate your Medicaid co-pay or deductible

If you have received a denial, you may still file an appeal, provided you have a compelling reason to believe that Medicare made a mistake in its decision.

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

  1. 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.
  2. 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.
  3. 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.

Please send the Law Firm of Kavesh, Minor & Otis, Inc. a message online, or call us at 1-800-756-5596 to schedule your free, no-obligation consultation.

Philip J. Kavesh
Nationally recognized attorney helping clients with customized estate planning guidance for over 40 years.
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