Medicaid Managed Care Denials: How to Appeal

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

Most people with Medicaid in Kentucky and Indiana get their care through a managed care plan. This is a private health plan that contracts with the state. If the plan denies, reduces or stops your care, you can appeal.

Federal Medicaid rules set the basic steps. Each state adds its own details, including the deadline for a state fair hearing. This guide covers both states. It is part of the Coverage & Appeals Center.

Is this your plan?

This page is for Medicaid managed care. In Indiana, that includes Healthy Indiana Plan (HIP), Hoosier Healthwise, Hoosier Care Connect and PathWays (IHCP module). In Kentucky, it means the managed care organization (MCO) named on your Medicaid card.

Medicaid is not regulated by the state Department of Insurance. The Indiana Department of Insurance lists Medicaid and HIP as outside its authority (IDOI: Jurisdiction). Your appeal goes to your plan first, then to the state Medicaid hearing process.

The steps at a glance

Either decision clock can be extended by up to 14 calendar days in some cases.

Step 1: Appeal to your Medicaid plan

1. Read the notice. Find the reason, the date on the notice and how to appeal. Use the denial decoder if the codes are unclear.
2. Mark your 60-day deadline. Count 60 calendar days from the date on the notice. The appeal deadline calculator can help.
3. Ask your clinician for support. A letter that answers the denial reason is your strongest evidence.
4. File your appeal. You can appeal by phone or in writing. In Kentucky, if you appeal by phone, send a signed written appeal within 10 calendar days (907 KAR 17:010).
5. Ask for a fast appeal if needed. If waiting could seriously harm your health, say so. The plan must decide within 72 hours (42 CFR 438.410).
6. Keep proof. Write down the date, the name of the person you spoke with and a reference number.

In Kentucky, the plan must acknowledge your appeal within 5 working days. If you asked to keep your benefits during the appeal, you may be able to keep getting them while you wait (907 KAR 17:010).

If the plan misses its deadline. Under federal rules, if the plan doesn’t follow the appeal timelines, you can go straight to a state fair hearing (42 CFR 438.408).

Step 2: State fair hearing

If your plan upholds its denial, you can ask the state for a fair hearing. A hearing officer who does not work for your plan hears your case. Federal rules let each state set a deadline between 90 and 120 calendar days from the plan’s decision notice (42 CFR 438.408).

Kentucky

• You can ask for a fair hearing only after you finish the plan’s appeal.
• Your request must be in writing.
• It must be postmarked or filed within 120 calendar days from the date of the plan’s final appeal letter (907 KAR 17:010).
• Follow the instructions in the plan’s final letter for where to send it.

Indiana

• After the plan’s appeal decision, you can ask for a state fair hearing, an external review by an independent review organization (IRO), or both.
• You have 120 days from the date of the plan’s decision (IHCP module).
• You must finish the plan’s appeal first.

A different Indiana deadline: 33 days. If you are in fee-for-service Medicaid (not a managed care plan), or you are appealing a decision about your eligibility, the deadline is 33 calendar days. These appeals go to the FSSA Office of Administrative Law Proceedings (Indiana Medicaid: Member Appeals; Medicaid Policy Manual ch. 4200). Read your notice closely to see which kind of decision it is.

A Medicaid appeal, start to finish

*This is an illustrative example, not a real patient.*

• May 1: Jordan, who has Medicaid managed care in Louisville, gets a notice that the plan will stop home therapy visits.
• May 3: Jordan calls the plan to appeal and asks to keep the visits going during the appeal. Jordan mails a signed written appeal on May 8, inside the 10-day window.
• May 20: Jordan’s clinician sends a letter explaining why the visits are still needed.
• Within 30 calendar days: The plan decides. If it upholds the denial, Jordan has 120 calendar days from that letter to ask in writing for a state fair hearing.

Prior authorization rules in 2026

Medicaid managed care plans are covered by the federal prior authorization rule CMS-0057-F. Starting in 2026 (CMS-0057-F):

• Urgent prior authorization requests must be decided within 72 hours.
• Standard requests must be decided within 7 calendar days.
• The plan must give a specific reason for a denial.

The rule does not apply to prescription drugs. If your plan denies a prior authorization, you can appeal it like any other denial. See denied for missing prior authorization.

[Your name]
[Your address] · [Your phone]

[Date]

[Plan name] — Member Appeals
[Address or fax from your notice]

RE: Appeal of adverse benefit determination
Member name: [Name]
Medicaid ID: [Number]
Service denied, reduced or stopped: [Service]
Date on the notice: [Date]
Reference number: [Number]

To whom it may concern:

I am appealing your decision to [deny / reduce / stop] [service]. Your notice dated [date] says: "[exact reason]."

I believe this care is medically necessary. My clinician explains why in the enclosed letter.

Enclosed are:
- Letter from [clinician]
- Medical records from [dates]
- A copy of your notice

[If you want services to continue:] I ask to keep receiving [service] while my appeal is decided.

[If urgent:] Waiting could seriously harm my health. I request an expedited appeal.

Please send me your decision in writing, with instructions for requesting a state fair hearing.

Sincerely,
[Signature]
[Printed name]

The appeal letter builder can help you fill this in.

Common mistakes

• Waiting for the state before appealing to the plan. In both states, you must appeal to the plan first.
• Appealing by phone only in Kentucky. Follow up with a signed written appeal within 10 calendar days.
• Using the wrong Indiana deadline. Managed care decisions allow 120 days for a fair hearing. Fee-for-service and eligibility appeals allow only 33.
• Not asking for a fast appeal. If waiting could harm you, say so.
• Calling the Department of Insurance. Medicaid appeals go through the plan and the state Medicaid hearing process.

Where to get help

• Your plan’s member services. Call the number on your Medicaid card and ask for the appeals department.
• Your notice. It must tell you how to appeal and how to ask for a fair hearing.

Not sure which route fits your situation? Try the appeal route wizard.