Home | News | Appealing a Medicaid Denial

If your family is applying for or is already covered by Medicaid or BadgerCare Plus and you have received a denial of benefits or eligibility, you should know that appealing the denial is not difficult. You have a right to appeal a denial and you are encouraged to do so, especially if you believe the denial was an error.

How Do I Appeal a Denial?

In order to appeal the denial, you will need to request a fair hearing. The hearing will allow you to be heard and explain your side of the story. A request can be made by:

  • calling the Department of Administration (DOA) at 608-266-3096
  • writing a letter requesting a fair hearing DOA, Division of Hearings & AppealsPO Box 7875 Madison, WI 53707
  • filling out the online form at www.dhs.wisconsin.gov/forms/F1/F10151.pdf

(PLEASE NOTE: If you need this information translated into Spanish or have specific questions about the appeals process and need this in Spanish, contact Mayra in the Milwaukee office at 414-227-3841.)

You have 45 days after you receive the denial to request a fair hearing. If you already have active benefits, you may consider appealing the denial within 10 days. If you call, write, or fill out the appeal request form online within 10 days, your benefits will continue until the matter has been resolved (until the hearing officer has issued his/her decision.) You will be notified of the date and time of the hearing in a letter in the mail, regardless of how you requested the fair hearing. Do not lose this letter.

What Should I Expect at the Hearing?

Fair hearings do not take place in a court room and you will not have to testify before a judge. In fact, you will be asked by the hearing officer to “raise your right hand and swear to tell the truth.” From that point forward, there are no formal rules of evidence and your conversation with the hearing officer will be rather informal. The casual hearing takes only 10- 15 minutes and is usually held in a small room with one officer. Lately, as a cost-savings measure, most hearings are being conducted by phone. If you feel you would like an in- person hearing, you should request that when you make your request for a fair hearing.

Before You Go to a Fair Hearing

Be organized and concise with explaining why the denial is incorrect. Since you only have 10-15 minutes, consider covering the following three points:

1. What denial did you get?
2. Why do you think it is wrong?
3. What proof do you have?

If you are able, provide the officer with medical records, relevant notes, financial statements or other documentation that specifically addresses your last point. Consider using post-it notes or highlighter to make the relevant information as easy to find as possible.

The hearing officer probably won’t tell you the outcome of the hearing until she has had a chance to review all the information. Consider asking the hearing officer the following questions before leaving:

  • “Are there other documents you need to see?”
  • “What information would help you make your decision?”If there is other information the hearing officer would like to see, ask that the “record be left open” so you have time to get that information to the hearing officer. Ask for an address or fax number to submit the information directly to the hearing officer.If you need help with this process, contact your Regional Center for Children and Youth with Special Health Care Needs and staff can walk you through the process (call 1-800-642-7837 to find the closest Regional Center) or call ABC for Health, a public interest law firm dedicated to ensuring health care access to children and families. They can be reached at 1-800-585-4222 or at www.safetyweb.org
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