Conquering The Medicaid Application: Part 5 - When The Application Is Denied

Application Denials and How to Start the Appeal Process



If an application is denied, the notice must state the reason for the denial and specific regulations. Many times, this is not done properly.

The notice also provides information regarding the appeal process.

An applicant can request a county conference or a State hearing. A State hearing can be requested without going through a county conference.



The appeal must be filed within 30 calendar days from the date of the notice. If a Medicaid recipient receives a notice terminating benefits, an appeal needs to be filed within 10 days in order for the benefits to continue during the appeal process. File appeals immediately for all people in current benefit status. If the county has unreasonably delayed the processing of an application, an appeal can be filed based on the county’s failure to timely process the application. However, talk to the technician first before filing the appeal. They are overworked. Squeaky wheels get grease.



An appeal requesting a county conference must be requested by contacting the case worker before the date the action is to be effective. A conference will be scheduled with someone from the county, other than the case worker processing the application, who will review the application with the applicant. If you think the decision of the county conference is wrong, you can then request a State hearing within ten days from the date of the conference decision.



An appeal requesting a State hearing needs to be in writing and it must state the reason for the appeal. The request needs to be filed with the Office of Administrative Courts, 633 17th Street, Suite 1300, Denver, Colorado 80202. The Office of Administrative Courts (OAC) will schedule a hearing and send a notice to all parties. Most of the time, these hearings are telephone hearings initiated by the Administrative Law Judge (ALJ) and the applicant needs to appear at the county office to participate in the hearing. If an applicant wishes to appear in person before the ALJ, a specific request must be submitted to OAC which includes the reason for the request.



The county is required to submit a letter stating the facts of the case, the reasons for the decision, and the rules and regulations supporting the decision. Along with the letter, the county is required to attach all exhibits upon which they intend to rely to support their decision, and a copy of the notice of adverse action. This information is required to be submitted to the ALJ no later than 5 days prior to the hearing. Although there is no requirement that the Appellant do the same, it is recommended that all documents which may be used as exhibits be provided in advance of a hearing, particularly a telephone hearing.



The hearing is fairly informal, but is conducted similar to any type of administrative hearing. Evidence and argument is presented on both sides. Hearsay evidence is admissible as long as it is deemed reliable and probative. Documents do not generally need to be authenticated unless there is an objection. Hearings are conducted in private unless the applicant requests a public hearing. No decision is rendered by the ALJ at the hearing. The ALJ must issue a written "Initial Decision" within 30 days after the hearing. For disability decisions and level of care decisions, the time is reduced to 20 days. The initial decision is not the final decision. The initial decision will be reviewed by the State and the State will issue a "Final Agency Decision". Unfortunately, there are no time periods for the State final agency decision but under federal law it must be "reasonably prompt". Generally that requires a final agency decision to be issued no more than 90 days from the date an appeal is filed.



Either party may "object" to the initial decision by filing "exceptions" with the State Department of Human Services. Responses and replies are permitted within certain time limits. The State will issue the final agency decision based on its review. Even if no exceptions are filed, the State has the option of overturning an ALJ’s initial decision. In order to appeal a final agency decision, an action must be filed in district court.





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