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The Medicaid Recipient Appeal Hearing

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

An Administrative Law Judge will conduct the hearing. The Judge will call you at the number listed on the Hearing Request Form, unless you have contacted the Office of Administrative Hearings and provided a different telephone number for your case after filing your appeal.  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.

The Judge will confirm that you received the Notice of Hearing.  The Judge will also ask if you have received copies of the exhibits.  Prior to the hearing, the exhibits will be sent to you by the attorney representing Medicaid.

You and the attorney representing Medicaid may make opening statements. This statement generally outlines the evidence you are about to present and your position concerning the case.

An attorney from the Attorney General's office will represent Medicaid. Generally, Medicaid will provide witnesses to explain the Medicaid policy and why the adverse decision was made.

Medicaid's attorney will ask the first questions. The Judge is neutral in these hearings but may ask some questions of all witnesses to be sure that certain legal points are presented. You will be able to ask questions after the attorney and Judge ask their questions.

After the Medicaid witnesses testify, you and any other witnesses you select will testify. The Judge will ask questions to be sure that legal points are covered, and you will be given an opportunity to make a statement at the end of your testimony.

Medicaid's attorney will ask questions of you and your witnesses after the Judge has finished.

You and Medicaid's attorney may make closing statements. This statement summarizes your position in the case.

At the end of the hearing, the Judge may ask you and/or Medicaid's attorney to submit a proposed decision and give a deadline for its submission.  A proposed decision contains the findings of fact and conclusions of law about your case that you would like to be included in the Judge's Final Decision.  The Judge may use some, all, or none of your proposed decision when drafting the Final Decision, because the Judge is not obligated to use any portion of your proposed decision, even if he/she rules in your favor.  For confidentiality reasons, Final Decisions in Medicaid Recipient Appeals are not published on OAH's website, but you may find examples of Administrative Law Judge Decisions in other OAH cases on the ALJ Decisions page.

Medicaid Recipient Appeals involving a Managed Care Organization (MCO)

An Administrative Law Judge will conduct the hearing. The Judge will call you at the number listed on the State Fair Hearing Request Form unless you have contacted the Office of Administrative Hearings and provided a different telephone number for your case after filing your appeal.  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.

The Judge will confirm that you received the Notice of Hearing.  The Judge will also ask if you have received copies of the exhibits.  Prior to the hearing, the exhibits will be sent to you by the attorney representing the managed care organization.

You and the attorney representing the managed care organization may make opening statements. This statement generally outlines the evidence you are about to present and your position concerning the case.

An attorney will represent the managed care organization.  Generally, the managed care organization will provide witnesses to explain the Medicaid policy and why the adverse determination was made.

The attorney for the managed care organization will ask the first questions. The Judge is neutral in these hearings but may ask some questions of all witnesses to be sure that certain legal points are presented. You will be able to ask questions after the attorney and Judge ask their questions.

After the managed care organization witnesses testify, you and any other witnesses you select will testify. The Judge will ask questions to be sure that legal points are covered, and you will be given an opportunity to make a statement at the end of your testimony.

The attorney for the managed care organization will ask questions of you and your witnesses after the Judge has finished.

You and the attorney for the managed care organization may make closing statements. This statement summarizes your position in the case.

At the end of the hearing, the Judge may ask you and/or the attorney for the managed care organization to submit a proposed decision and give a deadline for its submission.  A proposed decision contains the findings of fact and conclusions of law about your case that you would like to be included in the Judge's Final Decision.  The Judge may use some, all, or none of your proposed decision when drafting the Final Decision, because the Judge is not obligated to use any portion of your proposed decision, even if he/she rules in your favor.  For confidentiality reasons, Final Decisions in Medicaid Recipient Appeals are not published on OAH's website, but you may find examples of Administrative Law Judge Decisions in other OAH cases on the ALJ Decisions page.