If your family or child is covered by Medicaid, including BadgerCare Plus, Katie Beckett or SSI-related Medicaid, and your benefits have been denied, reduced or ended, you have the right to appeal the denial. To appeal, or formally disagree with a decision, you can request a fair hearing or a pre-hearing conference.

Requesting a Fair Hearing

In most cases, to appeal the decision 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 in the following ways:

• • • Call the Department of Administration (DOA) – 608.266.7709.
    • Fill out the online form at dhs.wisconsin.gov/forms/F1/F10151.pdf
    • Write a letter requesting a fair hearing.

DOA, Division of Hearings & Appeals

PO Box 7875

Madison, WI 53707

For Spanish translation, or if you would like an interpreter for the appeals process, contact the DOA’s Milwaukee office at: (414) 227-3841.  

IMPORTANT!

You have 45 days after you receive the denial notification to request a fair hearing. To keep your benefits active, appeal the denial within 10 days.

Call, write or fill out the appeal request form online and your benefits will continue until the matter has been resolved or the hearing officer has issued a decision. You will be notified of the date and time of the hearing in a letter by mail, regardless of how you submitted your appeal. Please keep this letter.

What is a Pre-Hearing Conference?

You may be able to come to an agreement without waiting for a fair hearing by asking for a pre-hearing conference. You will meet with a local agency representative to explain why you think the denial of services or benefits is not correct. If they agree with you, the action will be corrected, and you can avoid the appeals process. If not, you can still request a fair hearing.

What Should I Expect at the Hearing?

Most fair hearings are done over the phone. In rare cases, you may need to travel to be seen before the Administrative Law Judge (ALJ). At the start of your call or meeting, you will be asked by the hearing officer to, “Raise your right hand and swear to tell the truth.” There are no formal rules of evidence, and your conversation will likely be casual. The hearing usually takes 10 to 15 minutes.

Before You Go to a Fair Hearing

Be organized when explaining why the denial is incorrect. Since you only have 10-15 minutes, think about covering the following three points:

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

If you are able, provide medical records, notes, financial statements or other documents that address your point. Try using sticky notes or a highlighter to make the information easy to find.

The hearing officer won’t tell you the decision until they have a chance to review all the information. Try asking the following questions before the end of your call or in-person meeting:

• • • Are there other documents you need to see?
    • What information would help you make your decision?

If there is other information requested, ask that the record be left open, so you have time to get the information to the hearing officer. Ask for an address and email to submit it directly.

Need Legal Advice about Appealing a Denial?

The following agencies can provide support and assistance on appealing a Medicaid denial:

• • • ABC for Health is a statewide public interest law firm dedicated to ensuring health care access for children and families. (608) 261-6939 or info@safetyweb.org.
    • Legal Action of Wisconsin offers those with low-income free legal advice and support, including issues related to appealing denials of public benefits like Medicaid, SSI, Foodshare and Marketplace insurance. (855) 947-2528 or complete the online intake form.

INFORMATION AND RESOURCES

Wisconsin Wayfinder: Children’s Resource Network: (877) Wisc-Way (947-2929). Wisconsin Wayfinder offers families one name and phone number to find services for children with special health care needs. Wayfinder connects you to a resource guide at one of the five Children’s Resource Centers in your area.

Do you need a resource in another format or a printed copy? Contact Lynn@fvofwi.org.