Medicaid Says My Medical Care or Item Isn't Covered by Medicaid. What Can I Do?

Medicaid Won't Pay for a Medical Service I Need. What Can I Do?
Request a Fair Hearing
Ask for "7104" Review
How Do I Show Medicaid I Meet the Ten Standards?

Medicaid Won't Pay for a Medical Service I Need. What Can I Do?

There are two things you can do on your own. You can ask for a "Fair Hearing." Or you can use another Medicaid process called 7104. We explain how to do both of these things on this page.

Medicaid will send you a written notice. The notice will say you are denied for the medical service you need. They will say the service you need isn't covered by Medicaid.

Request a Fair Hearing

You have a right to appeal any decision Medicaid makes about your health care benefits. An appeal is a legal word for making a formal statement that you disagree. When you appeal, you ask for a "Fair Hearing." A Fair Hearing is a legal proceeding. It's kind of like a meeting and kind of like an informal court hearing.

Do you want to appeal? Request a "Fair Hearing." Learn more about Fair Hearings and appeals on our Appeals page. You can appeal by calling Member Services at 1-800-250-8427. You have 90 days to appeal. The 90 days begins when you get the written denial notice from Medicaid.

Ask for a 7104 Review

You can also use the 7104 process. 7104 is a Medicaid rule. 7104 is just the letter and number of a particular Medicaid rule. 7104 is a rule that lets Medicaid give extra health care benefits in special cases.

Do you want to get extra health coverage for a specific medical service you need? You need to show Medicaid that the medical service you need is "medically necessary." "Medically necessary" is an important legal rule or "standard" that Medicaid uses to decide if it will pay for the medical service. Medically necessary means that you and the extra health care service you need meet ten standards. The ten standards are listed on the Request for Coverage Application form. Your health care provider must say that you meet all ten of these standards.

How Do I Show Medicaid I Meet the Ten Standards?

You need to fill out the Request for Coverage Application (Patient) form. Your health care provider needs to fill out the Request for Coverage Medical Need (Provider) form. Tell your provider about the ten standards. Give your provider the list of ten standards.

Ask your primary care provider to write a detailed letter that explains why you need this service. Your primary care doctor must tell Medicaid why the service is "medically necessary" for you to have this care.

Fill out the forms. Make a copy of the forms and the letter from your health care provider. Send the original letter and forms to the address on your denial notice. Keep a copy of the letter and forms for your records. You may need them later.

Did you fill out the Request for Coverage Application form and the Request for Coverage Medical Need form? Did you give the forms to Medicaid? Did Medicaid still deny you extra health benefits? Call us at (800) 917-7787 for help.