Do you help with Medicaid denials

Yes for Medicaid managed care denials. Traditional Medicaid uses state fair-hearing procedures which vary state by state; we can still help draft the request but the process runs through your state Medicaid office, not the insurer.

Medicaid managed care

If your Medicaid benefits are administered by a private plan (Amerigroup, Centene, Molina, UnitedHealthcare Community Plan, and so on), that plan is a "Medicaid managed care organization" and it follows the federal appeal rules at 42 CFR 438.400 through 438.424.

Basis Appeals supports these plans. The letter we draft cites 42 CFR 438.408 (standard resolution timeframes) and 42 CFR 438.410 (expedited resolution) and requests a plan appeal.

Key facts for managed-care appeals:

• You have 60 calendar days from the notice of adverse benefit determination to file an appeal (42 CFR 438.402)
• The plan must resolve a standard appeal within 30 calendar days
• The plan must resolve an expedited appeal within 72 hours
• If the plan upholds its denial, you can request a state fair hearing

State fair hearing

After the plan denies your appeal, you can escalate to a state fair hearing. Under 42 CFR 438.408, you have 120 days from the plan's notice of appeal resolution to request the state hearing. Each state runs this differently. On the $99 tier we include a state-fair-hearing request template. On the $199 tier we include a state DOI companion sheet with the mailing address and form URL for your state.

Continuation of benefits

If you appeal within 10 days of the plan's adverse benefit determination and you were already receiving the service, the plan usually has to keep providing it while the appeal is pending (42 CFR 438.420). The catch: if you lose the appeal, the plan can bill you for the continued services. Read that section carefully before requesting continuation.

What we cannot help with (yet)

• Traditional fee-for-service Medicaid denials in states where the state runs claims directly. Ask us and we will still draft, but delivery is state-specific.
• Medicaid eligibility redeterminations. These are eligibility appeals, not benefits appeals, and go straight to your state Medicaid office.
• CHIP appeals in states with a separate CHIP program. Similar rules to Medicaid managed care but the citation set is different.

What to gather before the intake form

• The Notice of Adverse Benefit Determination from your plan
• Your member ID
• The service or medication that was denied
• Your prescribing or ordering provider's notes if the denial is medical necessity
• Whether you want expedited processing (only if your health could be seriously jeopardized by waiting)

Language accommodation

Under 42 CFR 438.10, the plan must provide interpreter services and written notices in your primary language if the state has designated it. If you speak a language other than English and the plan did not accommodate you, note that in the intake form. The letter can flag it.

What to do next

Preview a Medicaid managed care draft at /new. Select "Medicaid managed care" as your plan type and include the plan name (Amerigroup, Molina, and so on). We will cite the right section of 42 CFR 438 for your situation.