About the AHCCCS Fair Hearing Process

In Arizona, the Medicaid agency offers health care programs for residents of Arizona is the Arizona Health Care Cost Containment System (AHCCCS).  This organization provides health care from one of their health care plans such as Cigna or Mercy Care.But what happens when there is a denial of services? In this blog, we talk about the denial of services, state fair hearing requests and the the process.

Denial of AHCCCS Services

After applying for Available AHCCCS Health Plans, it’s possible to be denied. For some, denial even comes after already being on the health care program. If this is the case, a notice might come saying the service will be terminated. This means you may find out services have been terminated when a  request for a wheelchair or surgery is denied. When services of any kind will not be provided, an appeal can be made to AHCCCS. Appealing AHCCCS Denial is asking for the organization to reconsider their decision or modify it.

After sending in the appeal with all necessary information, you then wait for a reply to see if coverage will either be accepted or reinstated. You will receive a Notice of Adverse Action or Notice of Decision or Notice of Appeal Resolution. If the reply is unfavorable, you then must request a State Fair Hearing in writing and submit this within 30 days to the AHCCCS.

State Fair Hearing Request

A fair hearing is your chance to inform the judge why you need the equipment or service your health plan will not provide to you. Your request for a Fair Hearing must be done in writing and the AHCCCS must receive it no later than thirty days after you received the notice they sent you. If you don’t ask for a hearing by this deadline, the decision will be final.

Once your request is received by the AHCCCS, they will send you a Notice of Fair Hearing. The hearing itself then should take place in about 20 to 40 days. Your notice will tell you when the hearing will occur – the date and time – and where it will be. It will likely be at the Office of Administrative Hearings. Once the hearing has taken place, the Administrative Law Judge will send a recommendation to the AHCCCS. The Director there will review everything and make his own final decision and mail that to you. If it is still unfavorable, the letter you receive will tell you about going to the Superior Court for review.

AHCCCS State Hearing Process:

  1. Ask for a service.
  2. Service is denied by health plan.
  3. Applicant must appeal the denial.
  4. Health plan reconsiders the original decision.
  5. If denied again Applicant must appeal for a Fair Hearing.
  6. A hearing date is set.
  7. Fair Hearing is held before the Office of Administrative Hearings.
  8. The AHCCCS makes a final decision.

AHCCCS Fair Hearing Attorney Representation

Having an attorney that understands the AHCCCS Fair Hearing Process may be necessary if you face denial of services or benefits. An attorney can plan your argument effectively and put the reasons together which show that denial is not correct. A Fair Hearing attorney knows how to gather all evidence and documentation needed to help you in your case. To ensure you are treated fairly and correctly, an administrative law attorney is the best choice.