Medicaid appeals in Oklahoma: hearing deadline and keeping benefits

Medicaid (SoonerCare (Oklahoma Medicaid)) denials in Oklahoma

Medicaid agency

Oklahoma Health Care Authority (OHCA)

Who holds the hearing

Oklahoma Health Care Authority, Administrative Law Judge (Grievance Docket) for OHCA decisions; most eligibility decisions made by Oklahoma Human Services (OKDHS) are heard by Oklahoma Human Services

Hearing deadline

30 days

The date OHCA sends the written notice (the date on the notice is not counted; a mailed request counts as filed when OHCA receives it)

How to ask for a hearing

• Form: Member Complaint/Grievance Form (LD-1) for appeals of OHCA decisions; Request for State Fair Hearing (LD-1S) after a SoonerSelect plan appeal. For an eligibility decision made by Oklahoma Human Services, follow the appeal instructions on that notice.
• Mail: Oklahoma Health Care Authority, Grievance Docket Clerk, P.O. Drawer 18497, Oklahoma City, OK 73154-0497
• Fax: 405-530-3444
• Online: Email docketclerk@okhca.org
• Phone: Grievance Docket Clerk 405-522-7217 (questions)

405-522-7217

Mail address

Oklahoma Health Care Authority, Grievance Docket Clerk, P.O. Drawer 18497, Oklahoma City, OK 73154-0497

What to include

Fill out the form completely and include the needed documents, or the appeal will not be heard. Explain the problem, the dates, the names of staff you dealt with, and what you want OHCA to do, and attach a copy of the notice.

Keeping your benefits during the appeal

When you send a written hearing request, you can ask that your existing services continue or be restored until the appeal is dismissed, withdrawn or decided against you. If your written request does not say either way, services are continued. Some denials do not qualify, such as services over a limit, prescription prior-authorization denials, drugs or services OHCA does not cover, pharmacy lock-in, and services not ordered by a provider. If you are in a SoonerSelect plan, see the plan rules below.

Law: Okla. Admin. Code 317:2-1-2.6

When the hearing is held

OHCA notifies you in writing of the hearing date and time. Hearings are usually by phone; to ask for an in-person hearing, send Form LD-4 at least 10 calendar days before the hearing. Member appeals are ordinarily decided within 90 days of a timely request.

Law: Okla. Admin. Code 317:2-1-2(b)(6), (b)(8)

Faster (expedited) hearing

Ask the Administrative Law Judge, with a copy to the OHCA Legal division, if waiting could jeopardize your life, health or ability to attain, maintain or regain maximum function. Say why. The request is ruled on within 3 working days, and if granted a decision is issued within 3 working days after the hearing.

Law: Okla. Admin. Code 317:2-1-2

Medicaid health plan (managed care) in Oklahoma

Appeal to the plan first

If you are in a SoonerSelect health or dental plan, appeal to the plan within 60 days of its adverse decision notice. The plan must decide within 30 calendar days (it may extend up to 14 days); it handles expedited appeals when waiting could harm your health. Step therapy appeals are decided within 72 hours (24 hours in exigent cases). Decisions on medical necessity must be made by clinicians, not by automated software. If the plan upholds the denial, ask OHCA for a state fair hearing with Form LD-1S within 120 days. To keep services during the plan appeal, ask within 10 calendar days of the plan's notice or by the effective date, whichever is later; during the state hearing, file within 120 days and ask for continued benefits within 30 days of the plan's appeal decision. Appeals about Medicaid eligibility or plan enrollment go straight to OHCA.

Then a state hearing

120 days

The date of the plan's notice upholding the denial

Source: the LD-1S form says the adverse benefit determination notice

If the plan is late

If the plan does not meet the federal notice or timing rules, you are treated as having finished the plan appeal and can ask OHCA for a state fair hearing.

Optional outside medical review

OHCA does not offer an external medical review for SoonerSelect grievances or appeals.

Law: Okla. Admin. Code 317:2-3-5, 317:2-3-5.1, 317:2-3-6, 317:2-3-9, 317:2-3-12; OHCA Form LD-1S

Write my appeal: free letters

Letter: Medicaid fair hearing request