Mediation/Before the Medicaid Recipient Appeal Hearing

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

When the Office of Administrative Hearings receives your Hearing Request Form, your case will be referred to a mediator to schedule a mediation for your case. Mediation is a voluntary opportunity for the parties to attempt to settle the case between themselves with the help of a neutral, third person and without the formality of the court. The mediator will contact you to set a time for the mediation. You may elect to participate in mediation or to decline.

Depending on the type of appeal, the mediation must take place within twenty-five (25) days after the Hearing Request Form is received by the Office of Administrative Hearings. Work with the mediator to be sure this deadline is met.

Most mediations are conducted by telephone.  If you do not wish for your mediation to take place by telephone, you may discuss this desire with the mediator when he/she contacts you to schedule the mediation.  Please be aware that many mediators do not have the facilities available to conduct in-person mediations and even if the mediator can conduct your mediation in-person, the Medicaid representatives may still choose to participate by telephone.  During the mediation phone call, the mediator will join the parties for discussion of a possible settlement.

The mediator will file a Report of Mediator with the Office of Administrative Hearings and the Department of Health and Human Services. The report will confirm what occurred at mediation.

If you do not reach a settlement of the case, your case will be scheduled for hearing with an Administrative Law Judge.  The Notice of Hearing will be sent via certified mail if you have not registered as an e-filer.  Please be sure to accept certified mail from the Office of Administrative Hearings.  If you are an e-filer, be sure to regularly check your email.

You will need to provide any documentation that supports your position.  Be sure to label all submissions with your case number, which is assigned to your case only after your Hearing Request Form has been received and processed by the Office of Administrative Hearings.  Your case number is found in the upper right corner of all documents sent to you by the Office of Administrative Hearings.  If you are unsure what your case number is and you have already submitted your Hearing Request Form to OAH, please call the Office of Administrative Hearings and request that the receptionist do a search using the beneficiary's name and provide you with the case number.  After labeling the documentation with your case number, send one copy to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714 (or fax 919-431-3100) and send another copy to Department of Health and Human Services, Department of Justice, PO Box 629, Raleigh, North Carolina 27602 (or fax 919-715-0473).  Submit documents at least 5 business days before the hearing and include the case number on all correspondence.

The attorney representing Medicaid will send you their exhibits prior to the hearing.  Please be sure to check your mail and email regularly during your appeal so that you receive all documents related to your case.

If you want other individuals to testify for you, you will need to either have them in the room with you at the time of the hearing or provide the Judge with the other telephone numbers when you are contacted for the hearing.  Be sure to inform anyone you wish to testify that you would like them to testify, provide them with the date and time of your hearing, and confirm the best contact number for the Judge to use to contact them on the hearing date.

The testimony and/or documentation you present must show that the Department of Health and Human Services made the wrong decision or did not follow applicable rules or laws in making the adverse decision.

If your request concerns Medicaid benefits you have been receiving, the benefits you received prior to the appeal will continue while your case is moving through the appeal process if you timely filed the appeal and you remain Medicaid-eligible. The prior benefits will continue as long as you remain Medicaid-eligible until there is a final decision in your case or your case otherwise concludes.

Medicaid Recipient Appeals involving a Managed Care Organization (MCO)

When the Office of Administrative Hearings receives your State Fair Hearing Request Form, your case will be referred to a mediator to schedule a mediation for your case. Mediation is a voluntary opportunity for the parties to attempt to settle the case between themselves with the help of a neutral, third person and without the formality of the court. The mediator will contact you to set a time for the mediation. You may elect to participate in mediation or to decline.

Depending on the type of appeal, the mediation must take place within ten (10) days after the State Fair Hearing Request Form is received by the Office of Administrative Hearings. Work with the mediator to be sure this deadline is met.

Most mediations are conducted by telephone.  If you do not wish for your mediation to take place by telephone, you may discuss this desire with the mediator when he/she contacts you to schedule the mediation.  Please be aware that many mediators do not have the facilities available to conduct in-person mediations and even if the mediator can conduct your mediation in-person, the MCO representatives may still choose to participate by telephone.  During the mediation phone call, the mediator will join the parties for discussion of a possible settlement.

The mediator will file a Report of Mediator with the Office of Administrative Hearings, the Department of Health and Human Services, and the managed care organziation. The report will confirm what occurred at mediation.

If you do not reach a settlement of the case, your case will be scheduled for hearing with an Administrative Law Judge.  The Notice of Hearing will be sent via US mail if you have not registered as an e-filer.  Please be sure to accept mail from the Office of Administrative Hearings and to check your mail regularly.  If you are an e-filer, be sure to regularly check your email.

You will need to provide any documentation that supports your position.  Be sure to label all submissions with your case number, which is assigned to your case only after your State Fair Hearing Request Form has been received and processed by the Office of Administrative Hearings.  Your case number is found in the upper right corner of all documents sent to you by the Office of Administrative Hearings.  If you are unsure what your case number is and you have already submitted your State Fair Hearing Request Form to OAH, please call the Office of Administrative Hearings and request that the receptionist do a search using the beneficiary's name and provide you with the case number.  After labeling the documentation with your case number, send one copy to the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714 (or fax 919-431-3100) and send another copy to the attorney for the managed care organization.  A list of managed care organizations and their attorneys is provided on the insert included with the Notice of Telephone Hearing sent by the Office of Administrative Hearings.  If you are unsure where to send your documentation, please call the Office of Administrative Hearings.  Submit documents at least 5 business days before the hearing and include the case number on all correspondence.

The attorney representing the managed care organization will send you their exhibits prior to the hearing.  Please be sure to check your mail and email regularly during your appeal so that you receive all documents related to your case.

If you want other individuals to testify for you, you will need to either have them in the room with you at the time of the hearing or provide the Judge with the other telephone numbers when you are contacted for the hearing.  Be sure to inform anyone you wish to testify that you would like them to testify, provide them with the date and time of your hearing, and confirm the best contact number for the Judge to use to contact them on the hearing date.

The testimony and/or documentation you present must show that the managed care organization made the wrong decision or did not follow applicable rules or laws in making the adverse determination.

If your request concerns Medicaid benefits you have been receiving, the benefits you received prior to the appeal will continue while your case is moving through the appeal process if you timely filed the appeal and you remain Medicaid-eligible. The prior benefits will continue as long as you remain Medicaid-eligible until there is a final decision in your case or your case otherwise concludes.