NJ Medicaid Appeals
Medicaid Eligibility Determinations
After an application is submitted, the Medicaid agency will eventually make an eligibility determination, and the application either will be approved or denied. If an application is denied, the applicant has a right to a Medicaid appeal by requesting a fair hearing. Denials are often made in error and an appeal is necessary to correct the error.
All Medicaid programs are required to issue a written denial to the applicant explaining the basis for the determination and procedures to appeal. Failure of the notice to explain the reasons for the denial or give adequate instructions to the beneficiary on how to appeal can void the denial of Medicaid services. In New Jersey, the applicant must appeal the denial in writing within 20 days of the receipt of the denial notice. Failure to file a timely appeal may result in the denial being affirmed. If the applicant appeals the denial on a timely basis, the State must grant the applicant an administrative hearing, called a Fair Hearing. At the Fair Hearing, the applicant may testify, witness may be presented and the hearing officer must provide a written plenary review of the evidence, and an adjudication of all issues on appeal.
Medicaid Appeal Hearings
Medicaid Fair Hearings are very informal. Although traditional court rules of procedure and evidence are followed, the hearing officer will frequently allow both sides great latitude to ensure that all relevant evidence is entered into the record. The ruling of the hearing officer is limited to whether or not Medicaid complied with federal and state rules and regulations in denying eligibility.
The appeals process does not end with the hearing officer’s decision. The Director of the State Medicaid agency must approve or reject the hearing officer’s ruling before it becomes official. If the initial denial of benefits is upheld by the Medicaid Director, the only recourse for a Medicaid applicant is to appeal to a court of law. In New Jersey, the appeal is to the Appellate Division of the Superior Court of New Jersey.
Medicaid Appeals Assistance
Attorneys at the New Jersey Law Office of Vanarelli & Li, LLC handle all levels of appeals to assist clients who have been denied Medicaid or other public benefits. Our work includes both Fair Hearings at the administrative level, and the more formal proceedings in state or federal court. While most cases are settled without court intervention, we have the experience necessary to take cases to the highest levels of review if required.
For additional information regarding Medicaid Appeals, call us at 908-232-7400 or click here to contact us online.