What Should You Do If You Are Denied Medicaid
There are a large variety of reasons why Medicaid applications are denied, for example, missing information, incorrect information or coding, failure to include required attachments, incorrect dates of service, or erroneous calculations.
Lamson & Cutner has an unbroken track record of success with the Medicaid applications that it has prepared and filed. Before taking the risk of doing it yourself, or hiring someone with inadequate knowledge or experience, you may wish to consider the consequences of a denied application.
Tips For Medicaid Appeals
- Appeal by thedeadlineWhen you receive a denial, the denial notification must tell you how to file anappeal. When looking at the instructions on how to appeal, the appeal deadlineis one of the most important pieces of information on your appeal notice. Youmust request your appeal within the deadline, or you will be required tojustify a late appeal. States have different deadlines, but the deadline willbe no more than 90 days from the date the denial notice was mailed .
- Appeal to the planand the stateMany times you can file your appeal with your plan first, but you should alsofile an appeal with your state Medicaid agency before your appeal deadline runsout. If the appeal with the health plan is upheld, you want to still be able toappeal to the state.
- Follow the appealformat requested by the stateSome states require that you request your appeal in writing, while in somestates you can request an appeal orally.
- Submit a writtenstatement of patient authorizationIf youfile an appeal on behalf of a patient, make sure to submit a written statement,signed by the patient, their parent if under age, or guardian if one isassigned, telling the Bureau of State Hearings that you have been givenauthority to represent your patient.
The Medicaid agency may deny a Medicaid application for a number of reasons, including the following:
- Missing documentation. You need to show proof that you are eligible for benefits, which usually means providing Social Security statements, bank records, property deeds, retirement accounts, and insurance records, among other things.
- Excess assets. In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in countable assets .
- Transferred assets. If you transferred assets for less than market value within five years before applying for benefits, you may be subject to a penalty period before you become eligible for benefits.
The Medicaid agency is required to issue the denial notice with 45 days of the application . When you get a denial notice, read it carefully. The notice will explain why the application was denied and specify how to file an appeal.
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Are you eligible?
Have A Compromise Number Of Hours In Mind
Be ready to explain what would happen if you do not get the service you requested. Sometimes CCM will offer you more hours than were originally approved, but still less than what you requested. This is called a settlement offer. Figure out the minimum number of hours of the service that are necessary to meet your medical need. If you are willing to settle for a lesser number of hours than requested, you may be able to resolve the case at mediation and avoid a hearing.
However, you do not have to accept fewer hours than you requested and can proceed to the hearing if you need more hours than they offer you.
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The Basics Of Medicaid Denial & Next Steps
At a basic level, this is what you need to know about being denied for Medicaid programs including Long Term Care, and what to do next. If one receives a Medicaid denial letter, it is most often due to assets or income above the limits. Another possible reason is human error. One has three options upon a denial of Medicaid:
1) Request a reversal2) Appeal3) Re-Apply
Now, lets get a little more in-depth on the process of becoming Medicaid-eligible after a denial of benefits.
Getting An External Review
If your private insurance company still says no to your appeal, or your child is in a life-threatening situation, you can ask TDI for an external review. TDI hires Independent Review Organizations with knowledge in insurance and health care to do these external reviews.
To file an external review:
- Fill out an external review form and send it to the insurance company. This might also be called an IRO form. The insurance company should have sent you this form when they sent you the claim denial letter for your child. If they didnt send it, you can call TDI at for help. You can also ask your childs doctor to fill out this form for you.
- Once your insurance company gets the IRO form, they will get in touch with TDI. TDI will assign an IRO to review your childs case.
- You will need to sign a release form giving the IRO permission to see your childs medical records. The IRO will get the records from the insurance company and keep them private.
- The IRO will decide within 20 days of being assigned the case if the insurance company will have to pay for treatment, and more quickly if your child has a life-threatening condition. Ask them when they will make a decision when you ask for the external review.
- The IRO’s decision is the final step in the state appeals process. Your insurance company must follow this decision.
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Review Your Options And Stay Covered
Losing Medicaid coverage can be very scary and shocking at first, especially if you have ongoing health issues.
If you are dealing with losing Medicaid, remember that it is not the end of the road. You have multiple options. Keep both your healthcare needs and budget in mind when making a decision about how to move forward. And if you end up at the hospital without insurance coverage, there are options even in that situation.
No matter what path you choose to follow once youre denied Medicaid or you are dropped from Medicaid, the most important thing to do is to obtain some type of coverage. The physical and financial safety that you get from having health insurance can end up being well worth any cost.
What If My Medicaid Application Is Denied
There are several reasons your Medicaid application might be denied. The most common reason is that you do not meet the income requirements. In other words, you make too much money. Heres another example: If you claim eligibility based on disability and the Department of Health and Human Services doesnt believe that you are disabled, then your application will be denied.
If the department denies your application you will receive a letter that explains why you were denied. The letter will also explain how you can appeal the denial of your Medicaid application. Here is what you need to know about the appeals process:
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How To Prevent Future Denials
Denials are frustrating, but they can also be prevented with the right processes. Billers can do a number of things to reduce the amount of denials they see. The following are some of the changes billers should make at their practice to reduce claim errors.
Code to the highest level of specificity
What is upcoding and why is it important to avoid? Upcoding is the process of billing for a more expensive procedure in order to earn more money, and its highly illegal. Although its typically done intentionally, there are instances where it could be done accidentally, and you dont want to end up in this situation. For this reason, its important to code as specifically as possible. There are thousands of different medical codes, making medical billing a complex process for all involved. Coding up to the highest digit possible, usually the 4th or 5th, is a good way to ensure no code is confused for another.
Verify coverage and eligibility ahead of time
Too often, insurance eligibility isnt verified before a patients appointment, leading to denials and other issues. Fixing this issue is as simple as asking your front-end staff to verify a patients insurance coverage and information before the appointment begins. This is one of the biggest ways your practice can prevent insurance denials from happening.
File claims on time
Stay up to date on payer requirements
Denied Medicaid Because Of Income Or Assets Above The Limit
If Medicaid offices inform an applicant that their benefits were denied due to not meeting financial eligibility criteria, meaning income or assets are above the limits, then the first thing to do is double check the limits.
Denied Because of Income
If an applicant feels the denial is simply incorrect because they do not have income above the states limit, then the easiest step is to request a reversal. The process of requesting a reversal following a Medicaid denial is simple: One contacts the Medicaid caseworker who handled their application , and reviews the documentation to find any errors that were made and identify the reason for an unfair or incorrect denial. This simple step can frequently cause a denial to be reversed.
When requesting a reversal with a Medicaid caseworker, be sure to be respectful. It might become necessary to take the case to a supervisor, or someone else slightly higher in the hierarchy at your states Medicaid offices.
It might be a good idea to contact a professional Medicaid planner to review an application and Medicaid denial letter before requesting a reversal, especially if one has complicated financial and/or marital issues.
If the Medicaid denial was correct, and the applicant does in fact have income above the limits in their state, it is possible to lower ones countable income and reapply. Methods to lower income for the purposes of applying for Medicaid include:
Denied Because of Assets
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The Medicaid Denial Notice
If an application for Medicaid benefits is denied, the written notice must specify the reason for the denial and provide enough detail to enable the applicant to determine how the decision was reached. For example, if the reason for denial of benefits is that the applicantâs income was too high, the notice should identify the specific income limit used and how the income was calculated.
If you receive such a notice of denial and you cannot understand the notice, perhaps you were not given enough information. Without specifics it is impossible to figure out whether the decision is based upon accurate information or is flawed in some way. The failure to provide specific information is a violation of your rights in and of itself. If you were denied benefits but cannot determine the reason, your appeal should complain not only about the denial itself, but also about the incomplete nature of the notice.
Financial Criteria: How To Know Ones Specific Limits
The most common reason an applicant is denied Medicaid is income or assets above the eligibility criteria. In most states, an applicants monthly income must be less than $2,523 per month in 2022, and their assets must be less than $2,000.
These figures will vary depending on many factors, including state of residence, marital status and the type of Medicaid for which one is applying, so its a good idea to get case-specific criteria via our quick-and-easy Medicaid Eligibility Requirements Finder tool.
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Further Appeals After The Medicaid Hearing
If you do not win at the fair hearing level, you have the right to appeal the decision further, using your state court system. In some states, you would appeal the hearing decision directly to the highest state court, while other states require intermediate levels of appeal. If the issue raised in your case is significant enough, a federal court action might be advisable. You will need the assistance of an attorney to determine the merits of further appeal and whether to proceed through the state court system or to bring an action in federal court. There are also deadlines for filing in court. Even if you ask the fair hearing officer to reconsider the decision, those deadlines may continue to run, so it is important to consult an attorney as soon as possible.
Copy And Track Your Documents
It is important when sending physical copies of your application and supporting documents that you do so in a manner that allows tracking of the shipment. As suggested by Gentreo, it is a good idea to provide a formal cover letter with your application listing all of the attachments that you are providing. The more organized and detailed your submission is, the better chance you have of it staying all together.
Additionally, if you are going to be clipping documents together, make sure that you use binder clips that hold them securely. Finally, always make copies of everything you send. This means even if you are sending a 2-inch stack of documents, make sure you have everything copied.
We at Gentreo suggest uploading copies of files or pictures of documents to your Gentreo Digital Vault where they will be stored safely and securely and readily available when you need them. This is why the Gentreo Digital Vault is so vital as losing documents and applications that took a lifetime to accumulate can all be lost in an instant if not saved properly.
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File An Appeal With The Plan
You should also file an appeal with the planas soon as you receive a denial.
The plan must reconsider its decision if theydid not talk with the doctor who is asking for the transplant for your patient. If you feel a decision was made withoutdiscussing the case with your patients physician, you have the right to askfor a reconsideration, and a new decision must be made within one business day.
How To Appeal A Medicaid Decision
Many people wonder what to do if Medicaid is denied. Fortunately, the appeals process is straightforward. Individual states may have their own rules regarding the exact steps that applicants need to take. However, the general rules that appealers need to follow are fairly consistent throughout the country. Once candidates receive their Medicaid denial notice, they must inform their program office that they wish to appeal the decision. Depending on the state, applicants may have different ways they can file this request.
One of the most common ways to begin appealing a Medicaid denial is to submit the request in writing. In some states, you may also be given a Medicaid appeal number you can call for assistance. Regardless of how you file your appeal, you need to explain why you are requesting this reconsideration. After the state receives your request, you will have time to provide additional documents to prove you qualify for benefits. After the Medicaid office has all the information it needs, a program worker will reevaluate your case. If you are denied at this level, you will have additional opportunities to appeal.
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Filing An Appeal With Medicaid
If your child has Medicaid, you can call your childs Medicaid provider or case manager and tell them that you want to appeal your childs denial of coverage. They will assign a person to help you with this. In Texas, Medicaid workers must count any phone call disagreeing with a denial of service as an appeal of that denial.
Its a good idea to call as soon as you receive the denial. There is a deadline to make an appeal, which should be included in the letter you get about your childs denial of coverage. Make sure to call with your appeal before the deadline and make a note of the time of your call so you dont have to explain a late appeal.
Medicaid must give you a written decision about your childs appeal within 30 days of receiving your phone call.
If your child is in an urgent or life-threatening situation, ask Medicaid for an expedited appeal when you call. In this case, Medicaid has to answer you within 1 day of your call if your child is in the hospital, and within 14 days otherwise.