Medicaid dental appeal letter

Sourced answer

Federal law gives the appeal to the enrollee, not to the provider. Under 42 CFR 438.402(c)(1)(ii) a provider may request an appeal on an enrollee's behalf only if state law permits and with the written consent of the enrollee, and the same paragraph bars a provider from requesting continuation of benefits. The enrollee has 60 calendar days from the date on the adverse benefit determination notice to file the plan appeal (438.402(c)(2)(ii)); the plan must resolve a standard appeal as expeditiously as the enrollee's health condition requires and no later than 30 calendar days (438.408(a), (b)(2)), extendable by up to 14 calendar days (438.408(c)(1)). A state fair hearing comes only after notice that the plan upheld the determination (438.408(f)(1); 438.402(c)(1)(i)), with a state-set window of no less than 90 and no more than 120 calendar days from the resolution notice (438.408(f)(2)). Where the plan fails the notice and timing requirements the appeal is deemed exhausted and the enrollee may go straight to the fair hearing (438.402(c)(1)(i)(A)). Continuation of benefits is a separate, non-automatic request the enrollee must make by the later of 10 calendar days after the plan sends the notice or the intended effective date, and it requires all five conditions in 438.420(b); if the final decision is adverse the plan may recover the cost of continued services, consistent with the state's usual recovery policy and the contract (438.420(d)). A practice's own payment, pricing, recoupment, or contract dispute is not a subpart F appeal: it follows the managed-care contract and state program rules, whose deadlines differ - Texas HHSC requires the dental contractor to resolve provider complaints within 30 calendar days, and Ohio gives a provider 30 calendar days after exhausting the plan's internal process to request an External Medical Review on a medical-necessity denial.