A local appeal can be used for disputes related to a denial, suspension, termination, or reduction of services and/or supports. The local appeal is the first step of contesting a negative e benefit decision and must be completed.
If you are a Medicaid Recipient, you have 60 calendar days from the date of the written Notice of Action/Adverse Benefit Determination to request a local appeal. If you request a local appeal within ten days of the adverse benefit decision, you will continue to receive your benefits until a hearing decision is reached (subject to limited exceptions). You may request a local appeal orally or in writing, but oral appeals must be confirmed in writing unless the provider requests expedited resolution. At your local appeal you should have an opportunity, in person or in writing, to present evidence and testimony and make legal and factual arguments. The Notice of the decision on a local appeal for a Medicaid recipient must be provided within 30 calendar days from the date the appeal is received. If you disagree with the local appeal decision you can file a Medicaid Fair Hearings Appeal (See Below).
How Do I Appeal a Denial of Medicaid Services?
DRM Guide for Medicaid Fair Hearings Appeal Process
Medicaid Fair Hearings Rights & Responsibilities (MAHS guide)
If you are Non-Medicaid Recipient, you have 30 days from the date the Notice is received to file a local appeal. You may request a local appeal orally or in writing, but oral appeals must be confirmed in writing unless the provider requests expedited resolution. At your local appeal you should have an opportunity, in person or in writing, to present evidence and testimony and make legal and factual arguments.
If you are not a Medicaid recipient, the Notice of Decision must be received within 45 calendar days from the receipt of the local appeal request.
All local appeal decisions must be in writing and include the results of the resolution and the date it was completed. If the appeal is not wholly in favor of the consumer, Medicaid recipients have the right to a State Fair Hearing (See the DRM Guide Above). Non-Medicaid recipients do not have access to the state fair hearing process unless the PIHP fails to respond to the grievance withing 60 calendar days – this would constitute an action and can be appealed for fair hearing.
The Michigan Mental Health Code also provides for the option of requesting a Second Opinion in two specific situations: 1) an applicant’s initial request for CMH services, and 2) when there is a request for inpatient hospitalization. The second opinion will be reviewed by a qualified person other than the person who originally denied services. Qualified professionals may include a physician, licensed psychologist, registered professional nurse, master’s level social worker or master’ level psychologist. Decisions on the second opinion will be provided within 5 business days of the person’s request; within 3 business days for inpatient hospitalization. A second opinion does not replace the right to file a local appeal whether you are a Medicaid recipient or not.
Additional information is available at https://www.michigan.gov/documents/mdhhs/Appeals_and_Grievances_Technical_Requirements_P-6-3-1-1_638444_7.pdf