Q about Medicaid external appeals/fair hearings (NJ)

amother

Babypink

Thu, Jan 03 2019, 1:25 pm

I had some questions about appealing insurance denials from Medicaid managed care insurance and about Medicaid fair hearings, and the difference between them. I'm located in NJ.

In another thread an amother mentioned that someone had posted an AMA about this but I couldn't find anything. If the poster of that thread or another poster could offer any insight on my questions, please respond.

amother

Babypink

Thu, Jan 03 2019, 7:47 pm

amother wrote:

I work in the field if I can help you...

My physician prescribed treatment for my child but Medicaid declined to cover it. The physician's office will appeal the decision but I'm almost certain that they'll decline again, so I'll need to go to external appeal. When another of my children was in this situation I filed an external appeal after the internal appeal process was exhausted, and the Independent Utilization Review Org decided in my favor. Since the Medicaid Fair Hearing seemed like more work and I was nervous about the hearing process I figured I'd try the external appeal first and only consider the Fair Hearing if I lost.

This time I think the IURO is less likely to decide in my favor. If that happens I'm thinking of filing for a Medicaid Fair Hearing. But I don't know much about how that process works. What are my chances of winning there if I've lost the IURO? Should I file for Medicaid Fair Hearing at the same time as the external appeal? Do I need an attorney for a Medicaid Fair Hearing?

The physician's office is handling the internal appeal but after that I'm on my own.

Any information or advice you can give would be helpful. Also can you be more specific about your work?