Appealing a MassHealth denial

On Behalf of | Dec 29, 2022 | MassHealth

As you get older, you begin to worry about your health and safety more. Quality, affordable medical care is suddenly one of your biggest priorities.

You may be a member of MassHealth, which provides elderly Massachusetts residents with the medical coverage they need. However, what happens if you receive a denial letter?

Denials come in various forms. You could be denied services altogether, receive fewer than you asked for or your current services could be terminated.

Your denial letter must state the reason for the denial

First, make sure you understand the reason for the denial. Some denials are for reasons that can be easily fixed. MassHealth may just need more information or documentation.

If you provide this to them, the denial may be reversed. You should then receive a new letter confirming that MassHealth will pay for the service.

Not all denials are this simple. A common reason for a denial is that the service is not medically necessary. While you and your doctor might believe that it is, MassHealth may not agree.

Your denial notice must provide a specific, detailed reason as to why the service is not medically necessary. You are entitled to this type of notice. The letter cannot simply state that the service was denied because it is not medically necessary.

Do not wait to appeal your denial

You can appeal a denial. Although there is an appeal deadline, file the appeal as soon as you can.

After your appeal is received, you will be scheduled for a hearing. This is your chance to provide testimony and evidence about why your request should be approved.

Evidence for your appeal hearing

A good piece of evidence is a letter from your doctor explaining why the services you requested are medically necessary. You should also have your medical records ready and be prepared to provide detailed testimony of your medical issues and needs.

Do not panic if you get a denial letter. There are ways to fight it and continue receiving the medical treatment you need. You can have an attorney with you at your appeal hearing, who can advocate for your best interests.