Denied a Medicaid Service by your Medicaid Managed Care Plan? Know Your Rights: File an Appeal!

If your Medicaid Managed Care plan denies a health care service, you have the right to challenge that decision by filing an appeal.  In managed care, the first step in the appeal process is known as a Grievance.  This article explains your rights during the Grievance process, and how to appeal beyond the Grievance by asking for an External Review and/or Fair Hearing if you are not satisfied with the outcome of the Grievance.    

How Do I File A Grievance? 

If your Medicaid Managed Care Organization (MCO) denies a health care service, you have the right to challenge that decision by filing an appeal.  In managed care, the first step in the appeal process is known as a Grievance.  You have 60 days to request a Grievance, but you must request it within 10 days to keep your current services—those that are now being denied—in place until the Grievance decision is made.  When the MCO receives your Grievance request, they are required to send you a written acknowledgement letter stating they received your Grievance request and giving you instructions about next steps.   

What If I Don’t Receive A Denial Notice? 

If you do not receive a notice in the mail telling you that the service is being denied, you can and should still request a Grievance!  Even though the MCO is required to mail written notice to consumers before denying a service, we often hear from clients that they never received the proper written notice in the mail.  If you did not receive a denial notice and you find out your services are being denied, call PHLP’s Helpline at 1-800-274-3258.  PHLP can help ensure your Grievance is filed and that you get the written notice you’re entitled to receive.  

How Long Does The Grievance Process Take? 

You should get a decision no more than one month (30 days) from the day you request the Grievance. That deadline may be extended up to 14 additional days, but only at your request; the MCO cannot take longer than 30 days unless you ask for an extension.  If you filed a Grievance and it has been more than 30 days and you still don’t have a decision, call PHLP’s Helpline for assistance.  

What If I Can’t Wait 30 Days For A Grievance Decision? 

If you have an urgent need for the services that were denied, you may request that the appeal be fast-tracked; this is called an Expedited Grievance.  In order to obtain an Expedited Grievance decision, your doctor must send the MCO a written statement explaining why waiting the normal timeframe will be harmful to you.  PHLP has template letters your doctor can use for this purpose.  It is best to consult with an advocate before expediting your Grievance; call PHLP to discuss the pros and cons of this process.    

What Happens During The Grievance 

The Grievance review is a meeting with the MCO where you get the chance to explain why your service(s) should be approved, and to submit supporting medical records as well.  The MCO must give you ten (10) days’ advance notice of the date, time, and location of the Grievance meeting.  You have the right to participate in that meeting by phone, in person, or by videoconference when available.  You must notify the MCO if you want to participate; otherwise, they can and will hold the meeting and decide without you!  The MCO is required to be flexible when scheduling the Grievance, so ask them to reschedule if they schedule the Grievance meeting at a time you are not available. 

The Grievance must be decided by a panel of at least three (3) people who were not involved in the decision you are appealing.  In all types of service denials, at least one third of the panel members must not be employed by the MCO.  In matters involving physical health or medical services like nursing or durable medical equipment, there must be one doctor on the panel with expertise and experience with the service(s) in question. 

What Happens After My Grievance 

You will get a decision in the mail telling you whether the decision was overturned (approved) or upheld (denied).  If your Grievance is overturned, that means the MCO has approved the services they previously denied.  They are required to implement that decision as quickly as possible, and no later than 72 hours from the decision. 

If Your Grievance Is Denied, You Have A Right To Request A Fair Hearing.

If the Grievance panel upholds the service denial, you can appeal by requesting a Fair Hearing.  A Fair Hearing must be requested in writing within 120 days, or within 10 days to keep current services in place until the Fair Hearing is decided.  You should send your request via certified mail with a return receipt to prove it was filed on time.  The Fair Hearing will be decided within 90 days of when you requested the Grievance, minus the number of days it took you to file your request for a Fair Hearing upon receiving the Grievance decision.  A Fair Hearing is an informal legal proceeding that takes place with an Administrative Law Judge from the Department of Human Services (DHS).  You must participate in the proceeding either in person or by phone, and both you and the MCO will have a chance to explain and support your position regarding the service(s) at issue.  For more information about Fair Hearings, contact PHLP’s Helpline.  

If Your Grievance Is Denied, You Should Also Request An External Review.  

You only have 15 days from the Grievance decision to file the External Review request, or 10 days to keep current services in place until the External Review decision is decided.  The decision takes up to 60 days.  The External Review is a separate appeal process that takes place concurrently with the Fair Hearing, but it is very different.  To request an External Review, you can simply call the MCO; no need to put the request in writing as with the Fair Hearing.  And unlike the Grievance or Fair Hearing, there is no “meeting” for the External Review.  Instead, an independent medical review company, randomly assigned by the Pennsylvania Department of Health, reviews the case to decide if they agree or disagree with the MCO’s Grievance decision.  If the External Reviewer disagrees with the MCO and feels the services should be approved, the MCO is bound by that decision and must approve the services right away; no later than 72 hours after the decision.  

For More Information 

PHLP advocates are here to guide you through the Grievance, External Review, and Fair Hearing processes.  In some cases, we can represent you in these proceedings as your lawyer or advocate.  For assistance with a service denial, call PHLP’s Helpline at 1-800-274-3258.