Medicaid Denials

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

A listing as of April 2018 of Elements of the Medicaid Appeals Process under Fee for Service, by State is available here:

State Medicaid Programs require National Drug Codes (NDC) on Outpatient Claims in order to recoup rebate monies from pharmaceutical Manufacturers. Therefore only NDC numbers that are listed in the Drug Products in the Medicaid Drug Rebate Program are covered drugs. State Medicaid Program denials may be due to no NDC reported, or the NDC reported may not be in the program file resulting in an “invalid NDC” denial. The file is posted quarterly and is available here: