Nivellark · U.S. patient guide

How to appeal a Medicaid managed-care coverage denial

If a Medicaid managed-care plan denies a covered service, you can ask the plan to review its decision. If the plan upholds the denial, you may be able to request a State fair hearing. The notice, your state’s rules, and your plan materials explain the steps that apply to your coverage.

Official sources reviewed October 26, 2026

Procedures and deadlines vary by state and plan

Applicable procedures and deadlines vary by state and plan, even though federal rules set a basic appeal framework. States choose several process timeframes and may provide additional steps or help. Your plan, type of decision, and state can affect how you file, what happens next, and deadlines for a State fair hearing or continued benefits. Check the denial notice and member handbook, then confirm local instructions with your plan and State Medicaid Agency.

Start with your denial notice

Steps to appeal a plan decision

  1. Check who sent the notice and what was denied

    Keep the full notice. Look for the plan name, date, service or item, reason for the decision, and instructions for asking the plan to review it. A denial by your managed-care plan is different from a notice that says you are not eligible for Medicaid; use the instructions in the notice you received.

    If the reason is unclear, call the number on the notice or your member card. Ask what coverage rule or records the plan used and how you can get copies of the information it relied on.

    • Mark the deadline and the phone, mailing, fax, or online method listed for an appeal.
    • Ask for language assistance or an accessible format if you need it to understand the notice or take part in the process.

  2. Confirm the plan-appeal deadline

    Federal Medicaid managed-care rules generally give an enrollee 60 calendar days from the date on the adverse-benefit-determination notice to ask the plan for an appeal. Read your notice and member handbook now, and contact the plan promptly if the deadline or filing method is unclear. Do not wait for a general guide to calculate a deadline for your case.

    The plan appeal and a later State fair hearing are separate steps with separate instructions. The state selects the fair-hearing deadline within the federal range described in the rule, so follow the date and instructions in the plan’s appeal decision and confirm them with your state.

  3. Ask the plan to review its decision

    Tell the plan which decision you are appealing and what you want it to review. Federal rules allow a plan appeal request orally or in writing; use the contact information in your notice and ask whether the plan needs any follow-up form or documents.

    Include information that relates to the plan’s stated reason. A treating professional may be able to help explain clinical details or provide relevant records. Keep a copy of everything you send and note when and how you sent it.

    • The denial notice and any related authorization or claim number.
    • The plan handbook section or coverage rule named in the notice.
    • Relevant medical records, referral or authorization information, or a statement from a treating professional, if available.
    • A submission receipt, confirmation number, or notes from calls with the plan.

  4. Read the plan’s response and next-step notice

    A plan’s standard appeal resolution timeframe is set by the state and may not exceed 30 calendar days under the federal rule; an expedited appeal timeframe is set by the state and may not exceed 72 hours. Limited extensions may be allowed. The decision notice should explain the result and, when the denial is upheld, how to request a State fair hearing.

    Federal rules require at least 90 and no more than 120 calendar days from the plan’s appeal-resolution notice to request a State fair hearing. The exact state deadline and filing steps within that range are in your notice and state instructions. If the plan misses required notice or timing rules, the federal regulation describes when an enrollee may go to a State fair hearing; contact your State Medicaid Agency for help understanding that step.

If waiting could seriously affect your health

Tell the plan promptly that you need an expedited (fast) appeal and explain why waiting for a standard review could put your health at serious risk. Ask the plan how to submit the request and whether your treating professional can provide supporting information. The plan’s notice explains how to reach it.

For expedited appeals, federal rules set a maximum resolution timeframe of 72 hours after the plan receives the appeal; state-established timeframes may be shorter, and limited extensions may be allowed. Ask the plan or state agency which process and deadline apply to your situation.

If existing services may stop or be reduced

If the notice says the plan will reduce, suspend, or end a service you already receive, contact the plan and state agency immediately. Ask whether you can request that the service continue while the appeal or hearing is pending, how to make that request, and the exact deadline. Eligibility depends on the circumstances and strict timing rules; do not assume services will continue automatically.

Where to verify your state’s rules

Start with the appeal instructions in your notice and the member handbook for your plan. Call the plan using the number on your member card or notice to confirm how to file and what deadline applies.

For the State fair hearing office, state forms, or help understanding local procedures, contact your State Medicaid Agency. Medicaid.gov provides a state-by-state contact directory. Ask the agency where to find the current Medicaid managed-care appeal and fair-hearing instructions for your state and type of coverage.

Official sources

For general steps that may apply to other kinds of health coverage, read the general health insurance appeal guide or return to patient resources.