Medicaid: Appealing a Denial

Medicaid: Appealing a Denial

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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 have the right to appeal the denial.

How Do I Appeal a Denial?

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 in the following ways:

  • Calling the Department of Administration (DOA) at 608.266.7709.
  • Writing a letter requesting a fair hearing.

DOA, Division of Hearings & Appeals

PO Box 7875

Madison, WI 53707

Please be aware: If you need this information translated into Spanish, or you have questions about the appeals process and want to speak to a Spanish language interpreter, contact the DOA’s 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 might think about  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 through the mail, regardless of how you requested the fair hearing. Do not lose this letter.

What Should I Expect at the Hearing?

Most fair hearings are done over the phone. In rare cases, you will need to travel to be seen in person 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.” From that point forward, there are no formal rules of evidence and your conversation with the hearing officer will most likely be informal. The hearing usually takes only 10 to 15 minutes.

What is a Prehearing Conference?

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

Before You Go to a Fair Hearing

Be organized and concise when 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 point. Consider using sticky notes or a 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 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 the hearing officer would like to see, ask that the record be left open so you have time to get the information to the hearing officer. Ask for an address, email or fax number to submit the information directly to the hearing officer.

If you need help with this process, call your Regional Center for Children and Youth with Special Health  Care Needs staff at 800.642.7837. They will direct you to 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 800.585.4222 or at safetyweb.org.

 

Need Legal Advice about Appealing a Denial?

Families with low income may qualify for free legal help at one of these agencies:

 

Thank you to staff at ABC for Health for providing information for this fact sheet!