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Filing a Contested Medicaid Recipient Appeal

Not all Medicaid Recipient Appeals follow the same appeal procedure, so it is important to refer to the documentation you received with the Hearing Request Form to understand the timeframe in which your appeal must be filed as well as the place(s) to which your Hearing Request Form must be sent.

Medicaid Recipient Appeals involving the NC Department of Health and Human Services (most appeals)

If you wish to appeal an adverse decision (a determination by the Department of Health and Human Services to deny, terminate, suspend, or reduce a Medicaid service or an authorization for a Medicaid service), you must complete the Medicaid Services Recipient Hearing Request Form, which is included with your adverse decision.  Return the completed Hearing Request Form to the Office of Administrative Hearings within 30 days of the date the adverse decision was mailed to you.  The address and fax number of the Office of Administrative Hearings are located on the Hearing Request Form.  It is recommended, but not required, that you make a copy of your completed Hearing Request Form for your records. 

Be sure that the reason for the appeal (the service denied or modified) is listed correctly in the center portion of your Hearing Request Form.

If you want someone to assist you with the appeal as your Representative, please list that individual's name, address, and telephone number in the provided space on the Hearing Request Form.  Please note that if you list a Representative, that individual has the authority to make decisions regarding your case, including whether to close your case, without your permission.

The Hearing Request Form must be signed by the Medicaid beneficiary or the beneficiary's legal guardian.  If you are the beneficiary or his/her legal guardian, you must sign your name, write the date you are completing the form, and BE SURE YOUR TELEPHONE NUMBER AND ADDRESS ARE LISTED CORRECTLY. It is your responsibility to be sure the Office of Administrative Hearings has the correct address to mail you information regarding your appeal and the correct telephone number where you may be reached for a telephonic hearing of your appeal.

If you wish to have an in-person hearing, you must contact the Office of Administrative Hearings for further instructions after receiving your Notice of Telephone Hearing.  In-person hearings are scheduled in Raleigh, unless you indicate that coming to Raleigh would be a hardship for you, and the Administrative Law Judge consents to schedule your hearing outside of Raleigh.

Medicaid Recipient Appeals involving a Managed Care Organization (MCO)

If you wish to appeal an adverse benefit determination from a managed care organization following the reconsideration review, you must complete the State Fair Hearing Request Form, which is included with your Notice of Resolution from the managed care organization.  Return the completed State Fair Hearing Request Form to the Office of Administrative Hearings and the managed care organziation within 120 days of the date the Notice of Resolution was mailed to you.  The address and fax number of the Office of Administrative Hearings and the managed care organization are located on the State Fair Hearing Request Form.  It is recommended, but not required, that you make a copy of your completed State Fair Hearing Request Form for your records. 

Be sure that the reason for the appeal (the service denied or modified) is listed correctly in the space provided on your State Fair Hearing Request Form.

If you want someone to assist you with the appeal as your Representative, please list that individual's name, address, and telephone number in the provided space on the State Fair Hearing Request Form.  Please note that if you list a Representative, that individual has the authority to make decisions regarding your case, including whether to close your case, without your permission.

The State Fair Hearing Request Form must be signed by the Medicaid beneficiary or the beneficiary's legal guardian.  If you are the beneficiary or his/her legal guardian, you must sign your name, write the date you are completing the form, and BE SURE YOUR TELEPHONE NUMBER AND ADDRESS ARE LISTED CORRECTLY. It is your responsibility to be sure the Office of Administrative Hearings has the correct address to mail you information regarding your appeal and the correct telephone number where you may be reached for a telephonic hearing of your appeal.

If you wish to have an in-person hearing, you must contact the Office of Administrative Hearings for further instructions after receiving your Notice of Telephone Hearing.  In-person hearings are scheduled in Raleigh, unless you indicate that coming to Raleigh would be a hardship for you, and the Administrative Law Judge consents to schedule your hearing outside of Raleigh.