Steps in the Medicaid appeals process

Steps in the Medicaid appeals process

| May 22, 2020 | Firm News |

The patients in long term care facilities often rely on funds from Medicaid to ensure that their needs are met. However, when Medicaid denies their application, it can make it difficult for them to receive the treatment that they are due. Knowing how the Medicaid appeals process works is an essential step for patients, their loved ones and their caretakers.

When an application is denied, Pennsylvania’s Medicaid agency must send a written notice.

If a patient’s application was denied, they will receive written notice from the agency detailing why the application was denied and any deadlines for appealing the decision. This notice should be kept as documentation of these deadlines and the stated reason for denial. The state must issue this denial notice within 45 days of the initial application for non-disability cases and within 90 days for applications based on a disability.

Requesting an appeal must be done according to Pennsylvania’s state guidelines.

A denial from the state Medicaid agency is not the end, but because each state’s process is unique it is important to understand the guidelines in Pennsylvania. Under Pennsylvania law, a written request must be filed in order to receive a hearing. This hearing must occur in a timely manner, and can either be conducted in person or by telephone.

During the hearing process, the Administrative Law Judge will review testimony and documentary evidence in order to determine whether the patient should be granted the requested medical assistance. The Rehabilitation & Community Providers Association (RCPA) recommends having a physician write a clear letter of medical necessity to document why they believe that the treatment, medication or service was necessary to maintaining the patient’s health.

After the hearing, the patient will receive notice of the results.

When the hearing has concluded, the Administrative Law Judge will make a decision and the patient will receive written notice of the results. If they are successful, then their enrollment in the Medicaid program will be approved, and they may receive retroactive coverage to offset the impact of the lack of coverage during the appeals process. If the hearing was unsuccessful, however, this notice will include information on appealing this decision.

Because the process of Medicaid appeals can be complex, it can be important to work with an attorney that has experience working with long term care facilities. Their knowledge can help ensure that facilities have required documentation in order, that they meet deadlines and that the appeal has the evidence it needs to support a positive outcome.