Phone script: appeal to your Medicaid plan and keep services going

Date and time of this call: [Date and time of this call] Before you call, have the notice, the member's Medicaid identification (ID) number, a pen and paper. Call the member services or appeals number printed on the notice. Call as soon as you can.

Know your dates before you dial. To appeal, you have 60 calendar days from the date on the notice. To keep services going during the appeal, you must ask within 10 calendar days of the date the plan sent the notice, or before the change takes effect if that is later. Your notice is dated [Date on the denial notice] and the change takes effect on [Date the notice says the change takes effect]. The date on your notice controls.

1. Say: "My name is [Your name]. I am a member of [Name of the health plan]. My Medicaid ID number is [Member ID]. I received a notice dated [Date on the denial notice] that says: [What the notice says will change]." 2. Say: "I want to appeal this decision, and I want my services to keep going at the current level while the appeal is decided. Please record both requests today." 3. Say: "These services were already approved and were ordered by [The doctor or provider who ordered the service]. The notice says they change on [Date the notice says the change takes effect]. I am asking within the time the notice allows." 4. Ask: "May I have your name and a reference number for this call?" Write both down. 5. Ask: "Please confirm in writing that you received my appeal and my request to keep services going, the date you received them, and whether my services will continue. What address or fax number should I use to send my letter as well?" Write down the answer. 6. Ask: "Please send me my case file, including my medical records, free of charge. How and when will I get it?" 7. Ask: "Is a fast appeal available?" Ask for one only if waiting could harm health. A fast appeal must be decided within 72 hours. 8. Ask: "What date will you decide my appeal?" Write it down. A standard appeal must be decided within a state-set period of no more than 30 calendar days. 9. If you are told "the provider must ask for this" or "have the doctor call us": say, "Under the federal rules for Medicaid plans, the member is the one who asks for services to continue, and a provider cannot ask for the member. I am asking now. Please record my request. If you say it cannot be accepted from me, please tell me the reason in writing and give me your supervisor's name." 10. If you are told the approval for these services has already run out: ask, "What date did the approval end, and where does it say so? Please put it in writing." 11. If you are told no, ask: "Please send the reason in writing. What is my deadline to ask for a state fair hearing?" 12. Write down: the name of the person, their ID number if they give one, the date and exact time of the call, the reference number, whether the plan agreed to continue services, what was promised and by when, and the number you called. 13. Close: "Let me repeat what we agreed." Read your notes back and ask, "Is that right?" Say, "I will send my appeal in writing today."

Do not rely on the call alone. Send the appeal letter the same day and keep a copy.