Is there a federal deadline to appeal a Medicaid enrollment denial?

No. Under 42 CFR 455.422, states must give denied or terminated providers whatever appeal rights state law or regulation provides. The deadline is in your denial notice and the state rule it cites.

Can a Medicaid MCO contract with me before the state enrolls me?

Yes, for a limited time. Under 42 CFR 438.602(b)(2), a plan may sign a provider agreement pending state enrollment for up to 120 days, but must terminate it if the state says you cannot be enrolled or the 120 days pass without enrollment.

Does a Medicare termination affect my Medicaid enrollment?

It can. States must deny or terminate providers terminated by Medicare who appear in the federal termination database (42 CFR 455.416(c)), and New York automatically terminates participation as of a Medicare termination date.

When can I reapply in New York after a Medicaid enrollment denial?

Under 18 NYCRR 504.5(d), once you correct the factors that led to the denial, or after two years if the factors relate to prior conduct of the applicant or an affiliated person.

Medicaid Enrollment Denials and Provider Appeals

Medicaid enrollment is a state decision, but federal regulations set the floor. When a state Medicaid agency denies or terminates your enrollment, the consequences reach further than fee-for-service billing. Under 42 CFR 438.602(b)(1), the state "must screen and enroll, and periodically revalidate, all network providers" of its managed care plans. A plan may sign you "pending the outcome" for up to 120 days, but "must terminate a network provider immediately upon notification from the State that the network provider cannot be enrolled, or the expiration of one 120 day period without enrollment" (438.602(b)(2)).

That is why a Medicaid MCO's "rejection" is sometimes a state enrollment problem in disguise. Before disputing anything with a plan, confirm your status with the state.

When must a state deny or terminate enrollment?

The federal screening rules are in 42 CFR Part 455, subpart E. Section 455.416 lists mandatory and discretionary grounds. The state must deny or terminate when:

A person with a 5 percent or greater ownership interest was convicted of a criminal offense related to Medicare, Medicaid or CHIP in the last 10 years, unless the agency documents in writing that denial is not in the program's best interests (455.416(b)).
The provider was terminated on or after January 1, 2011 by Medicare or another state's Medicaid or CHIP program and appears in the termination database (455.416(c)).
The provider or an owner, agent or managing employee "fails to submit timely or accurate information," again unless the agency documents a best-interests exception (455.416(d)).
Required fingerprints are not submitted within 30 days of a request (455.416(e)), or the provider does not permit a site visit (455.416(f)).

The state may deny or terminate when information was falsified or the applicant's identity cannot be verified (455.416(g)). States also must check federal databases, checking the OIG's List of Excluded Individuals/Entities and the Excluded Parties List System "no less frequently than monthly" (455.436(c)(2)).

Several of these grounds are administrative. A missed fingerprint request, an unanswered information request or a disclosure that did not match an ownership record is fixable, and fixing it fast is often better than appealing.

Which problems can be fixed without an appeal?

Several of the mandatory grounds carry their own escape valve. For an owner's conviction, a failure to submit timely or accurate information, missed fingerprints, or a refused site visit, the state may decide that denial or termination "is not in the best interests of the Medicaid program" and document that in writing (455.416(b), (d), (e) and (f)). A prompt, complete cure gives the agency a reason to use that discretion.

Other federal rules can also help:

Screening already done. A state may rely on screening results from Medicare contractors or another state's Medicaid or CHIP program (455.410(c)). If you are enrolled in Medicare in good standing, point that out.
Cost-sharing claims. The state "must allow enrollment of all Medicare-enrolled providers and suppliers for purposes of processing claims to determine Medicare cost-sharing" if they meet federal Medicaid enrollment requirements, even if the provider type is not one the state otherwise recognizes (455.410(d)).
Ordering and referring. States must require physicians and other professionals who order or refer services to be enrolled (455.410(b)), so a denial can affect your patients' prescriptions, labs and referrals even if you never bill Medicaid directly.

Who sets the appeal rights?

The state. Federal law says only this, in 42 CFR 455.422: "The State Medicaid agency must give providers terminated or denied under § 455.416 any appeal rights available under procedures established by State law or regulations." There is no single national deadline. Read the denial letter for the deadline and the address, then confirm it against the state rule it cites.

How do three states handle it?

New York

New York's rule is 18 NYCRR 504.5. A denial must come with "a written notice of the denial, stating the reason or reasons." The applicant "may appeal the denial by filing a written request for reconsideration with the department within 45 days of the date of the notice of denial," and the request "must include all information which the applicant wishes to be considered." The department issues a written determination within 60 days of receiving the request, and that determination "will be the final decision of the department." If a denial stands, you "may reapply only upon correction of the factors leading to its denial, or after two years if the factors relate to prior conduct" (504.5(d)).

New York's list of factors is also unusual: alongside conduct-based reasons, the department may consider "the current availability of medical care, services or supplies to recipients (taking into account geographic location and reasonable travel time)" (504.5(a)(14)). An access argument can therefore be relevant even at the state enrollment stage. See New York network access laws.

Pennsylvania

Pennsylvania's rule for terminated enrollment is 55 Pa. Code 1101.84. A written Notice of Appeal "shall be filed within 30 days of the date of the notice of termination," is "considered filed on the date it is received" by the Director of the Office of Hearings and Appeals, and must include a copy of the termination letter, state the actions appealed and "explain in detail the reasons for the appeal." If the termination followed a Medicare termination or a criminal conviction, the appeal is limited to "the issue of identity." See Pennsylvania network access laws.

Ohio

Ohio Admin. Code 5160-1-17.8(H) says that if enrollment "is denied as a result of failure to meet the provider screening requirements or failure to pay any associated application fee, the provider may request a hearing pursuant to Chapter 119. of the Revised Code." The deadline comes from that chapter and the notice; read the notice the day it arrives. See Ohio network access laws.

What should a request for reconsideration include?

The letter and the rule it cites. Quote the exact ground. A denial for "failure to submit timely or accurate information" needs a different answer from one based on another state's termination.
Proof of cure. Fingerprint receipts, corrected ownership disclosures, confirmation of a completed site visit, or a reinstatement letter from the program that terminated you.
Identity proof if the state matched you to someone else's record. In Pennsylvania, identity may be the only issue you can raise after a Medicare-based termination.
Everything at once. New York's rule asks for "all information" with the request, and the decision after reconsideration is final at the department level.

When does a Medicare problem become a Medicaid problem?

Often. Section 455.416(c) requires denial when the provider is in the termination database after a Medicare or other-state termination. New York's 18 NYCRR 504.7(c) says participation "is automatically terminated or suspended as of the date of the provider's suspension or termination from Medicare." If the root cause is a Medicare revocation, the Medicaid appeal may go nowhere until the Medicare issue is resolved; see Medicare revocations and corrective action plans.

How does this affect your managed care contracts?

Once you are enrolled, the managed care side has its own rules. Each state must set a uniform credentialing and recredentialing policy that its plans follow (42 CFR 438.214(b)), and a plan that declines you "must give the affected providers written notice of the reason for its decision" (438.12(a)(1)). Those rules are covered in the Medicaid managed care rule against provider discrimination and each state's uniform Medicaid credentialing policy. For first-time state enrollment, our sister service explains how to become a Medicaid provider.

Where does a fair hearing fit?

Some states route enrollment appeals to an administrative hearing (Ohio's Chapter 119 hearing is one). A hearing involves testimony, exhibits and legal argument before a hearing officer. That is the point to bring in a healthcare attorney. We do not represent providers at hearings and we do not give legal advice.

What do we prepare, and what do you send?

In a Network Rejection Review ($249, credited toward a dispute), we read the state's letter, identify the 455.416 ground and the state rule, calendar the appeal deadline, and check whether a Medicare action is driving it. In a Payer Network Dispute ($799), we prepare the reconsideration request and organize the cure evidence. You review, sign and send it to the agency, and we track the response. Prices are listed on our pricing page.