All state Medicaid programs are required to have a process for beneficiaries to appeal coverage decisions. The right to appeal is established in federal statute and regulation and based on the constitutional right to due process. In Medicaid, due process protects a beneficiary’s claim to services by providing notice of state actions and providing beneficiaries with an opportunity for a hearing to review those actions. These standards were set forth in the U.S. Supreme Court’s 1970 decision in Goldberg v. Kelly.
Beneficiaries may appeal a decision regarding a fee-for-service claim directly to the state Medicaid program. States are required to offer a fair hearing to beneficiaries whose claim is denied or not acted upon with reasonable promptness, but states have flexibility in the design of the appeals process.
This compendium describes the elements of the Medicaid appeals process under fee for service; provides an overview of the steps in each state’s fee-for-service appeals policies; and provides summaries of the key provisions of each step in each state’s appeals process taken directly from state statute and regulation, with links to the legal documents. The compendium does not cover managed care services nor those provided in nursing facilities.
Read the fact sheet on federal requirements and state options for the Medicaid appeals process.
