File an appeal: Apple Health (Medicaid)
Apple Health (Medicaid) providers, applicants, and recipients may appeal HCA decisions in certain circumstances. They do this by requesting an administrative hearing.
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Apple Health applicants and recipients
The Health Care Authority and our partner, the Department of Social and Health Services (DSHS), make eligibility and coverage determinations for Medicaid Titles XIX and XXI of the Social Security Act.
When does an applicant or recipient have a right to a hearing?
If you have received a letter or notice from Apple Health and are aggrieved by a decision, you may have a right to a hearing. Follow the directions on your letter and complete any form that came with your letter to request a hearing.
Appealing decisions from managed care organizations (MCOs)
If you are appealing a decision from a managed care organization (MCO) such as Wellpoint (formerly Amerigroup), Community Health Plan of Washington, Coordinated Care, Molina Healthcare, and United Healthcare, you must exhaust all levels of resolution and appeal within the MCO’s grievance system prior to requesting an administrative hearing. WAC 182-526-0200. The MCO will send you and your provider a copy of the denial with the steps on how to appeal the decision.
How does an applicant or recipient request a hearing?
- Use any forms or follow directions included with the decision letter you are appealing.
- Contact the Office of Administrative Hearings (OAH) at 800-583-8271.
An administrative law judge at OAH will conduct a hearing either by telephone or in person, and then issue an initial order.
Applicants and recipients may request review of the initial order from the Board of Appeals, which will issue a final order.
Resources for Apple Health applicants and recipients
The resources below may be helpful when you are preparing for your hearing and, in general, assisting you through the appeal process. (The resources below are intended to assist you in the overall process and are not intended to provide legal advice.)
- Coordinated Legal Education Advice and Referral (CLEAR) may help you find free legal assistance.
- Washingtonlawhelp.org lists information and resources about our administrative hearings.
- Free and Reduced-Fee Legal Assistance lists information from the Washington State Bar Association that may assist you in searching for free and low cost legal assistance.
- OAH’s Hearing Preparation Information for WA Apple Health has information on how to navigate through and prepare for the administrative hearing process.
Apple Health providers
When does a provider have a right to a hearing?
You may have a right to a hearing--as identified in your notice or remittance advice--if you are a provider assessed with an over payment under RCW 41.05A.170.
An administrative law judge at the Office of Administrative Hearings (OAH) will conduct a hearing either by telephone or in person and then issue an initial order.
Providers may request review of the initial order from the Board of Appeals, which will issue a final order.
If you need information or assistance in submitting a claim, please contact the HCA Medical Assistance Customer Service Center.