Medicaid appeals in North Carolina: hearing deadline and keeping benefits

Medicaid (NC Medicaid (including NC Medicaid Managed Care)) denials in North Carolina

Medicaid agency

N.C. Department of Health and Human Services, Division of Health Benefits (NC Medicaid), and county departments of social services

Who holds the hearing

N.C. Office of Administrative Hearings (service denials); county department of social services and NCDHHS (eligibility)

Deadline for service decisions

30 days

The date the notice was mailed, for a service denial by NC Medicaid outside a health plan (file with the Office of Administrative Hearings). For an eligibility decision (denial or end of Medicaid), you have 60 days from the date of the action to appeal to your county department of social services.

Deadline for eligibility decisions

60 days

How to ask for a hearing

• In person: Eligibility (denial or end of Medicaid): give notice of appeal to your county department of social services; if you disagree with the local hearing decision, appeal to NCDHHS within 15 days of the mailing of that decision
• Form: Service denials by NC Medicaid (not a health plan): return the Medicaid Services Recipient Hearing Request Form sent with your notice to the Office of Administrative Hearings within 30 days of the date the notice was mailed
• Mail: NC Office of Administrative Hearings, 1711 New Hope Church Road, Raleigh NC 27609
• Fax: OAH main fax 984-236-1871 (use the fax number printed on your hearing request form)
• Phone: You can request a service or managed care hearing by calling the number on the hearing request form; OAH 984-236-1850

984-236-1850

Mail address

NC Office of Administrative Hearings, 1711 New Hope Church Road, Raleigh NC 27609

What to include

The hearing request form asks for your name, address, phone number and Medicaid ID, the service denied or changed, and your signature (or your legal guardian's). List any representative's name, address and phone.

Law: N.C. Gen. Stat. 108A-79, 108A-70.9A, 108D-15

Keeping your benefits during the appeal

For eligibility, your Medicaid continues at the same level until the local hearing decision if you request a hearing on or before the date the termination or change takes effect. For service cuts by NC Medicaid, services continue until the hearing decision if you request a hearing before the effective date of the decision. You may have to repay if you lose.

Law: N.C. Gen. Stat. 108A-79(d), 108A-70.9A; N.C. Gen. Stat. 42 CFR 431.230; N.C. Gen. Stat. 108A-79, 108A-70.9A, 108D-15

When the hearing is held

For eligibility appeals, the final decision must come within 90 days from the date you requested the hearing unless you asked for a delay; the county's local hearing may not be held more than 15 days after the request even with a delay for good cause.

Law: N.C. Gen. Stat. 108A-79; N.C. Gen. Stat. 108A-79, 108A-70.9A, 108D-15

Ombudsman

NC Medicaid Ombudsman · 1-877-201-3750

Medicaid health plan (managed care) in North Carolina

Appeal to the plan first

If you are in an NC Medicaid health plan, appeal to the plan within 60 days after the mailing date of the denial notice. The plan must decide within 30 days, or within 72 hours for an expedited appeal; a request from a network provider is presumed to need an expedited appeal. If the plan says no, file the State Fair Hearing Request Form sent with the notice of resolution with the Office of Administrative Hearings within 120 days after it was mailed, by mail, fax or phone.

Then a state hearing

120 days

The mailing date of the plan's notice of resolution

If the plan is late

If the plan does not follow the federal appeal rules, you are treated as having finished the plan's appeal and can ask for a hearing.

Law: N.C. Gen. Stat. 108D-13, 108D-14, 108D-15

Write my appeal: free letters

Letter: Medicaid fair hearing request