Nevada Medicaid Appeals: How to File and Keep Benefits

If Nevada Medicaid denied, reduced, or terminated your coverage, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is pending.1 Federal Medicaid law guarantees that hearing to every applicant and beneficiary, gives you up to 90 days from your notice to ask for it, and lets your services continue while you wait if you act in time.2,3 In Nevada, you file that request with the Nevada Medicaid Hearings Unit, and the deadline that protects your coverage is shorter than the one that protects your appeal.4

In This Guide

• What you can appeal in Nevada Medicaid
• The deadlines that decide your Nevada Medicaid appeal
• How to keep your benefits during the appeal
• Managed care (MCO) appeals in Nevada Medicaid
• How to request a Nevada Medicaid fair hearing
• Frequently Asked Questions

What you can appeal in Nevada Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency. Section 1902(a)(3) of the Social Security Act (42 USC 1396a(a)(3)) requires Nevada's Medicaid plan to give a hearing to anyone whose claim for medical assistance is denied or is not acted on promptly, and 42 CFR 431.220 extends that right to anyone who believes the agency acted erroneously or made an adverse determination.1

In Nevada, a recipient who disagrees with a denial, reduction, suspension, or termination of covered services may request a Fair Hearing.4 In practice, that means you can appeal:

• A denial of covered services, in full or in part
• A reduction of a service, including a cut to authorized personal care hours
• A suspension or termination of a service you were already receiving
• A prior authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service

The right reaches across the program, whether your care is delivered fee-for-service or through a managed care plan. What differs is the path you take to the hearing and the deadlines that apply along the way.

The deadlines that decide your Nevada Medicaid appeal

Two deadlines govern a Nevada Medicaid appeal, and they are not the same number: 90 calendar days to request the hearing, and 10 calendar days to keep your benefits flowing while it is decided.2,4

Under 42 CFR 431.221(d), a state must allow up to 90 days from the date the notice of action is mailed to request a fair hearing, and that 90 days is the federal ceiling.2 Nevada uses that full window: Medicaid must receive your request within 90 calendar days from the Notice Date shown on your Notice of Decision.4 Read the Notice Date off your own notice and count from there.

The second window is shorter and controls whether your services keep flowing during the appeal. To have your services stay the same during the Fair Hearing process, you must ask for the hearing not more than 10 calendar days after the Date of Action on the notice.4 Missing it does not end your right to a hearing, but it can end your coverage while that hearing plays out. The next section explains how continuation works.

One more rule protects renewals specifically. If Nevada ended your coverage only because you did not return a renewal form or requested information on time, you do not always have to reapply: under 42 CFR 435.916, if you submit the renewal form or the missing information within 90 days after the termination date, the agency must reconsider your eligibility without a new application.6

How to keep your benefits during the appeal

Keeping your benefits during a Nevada Medicaid appeal is called aid paid pending. It is never automatic: you have to ask for it, and you have to ask in time.

Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the action takes effect, the agency may not terminate or reduce your services until a decision is rendered after the hearing, unless the only issue is one of federal or state law or policy.3 The trigger is the date the action takes effect, not a flat count of days.

Nevada's Notice of Decision spells out two steps to keep services unchanged: ask for a hearing not more than 10 calendar days after the Date of Action, and specifically ask that your services stay the same.4 Do both, and your services continue throughout the Fair Hearing process.

If your services continue during the appeal and you lose, Medicaid may ask you to pay back the cost of the continued services.4 That repayment applies only to the services furnished because benefits were continued.

When an adverse-action notice arrives, find the Date of Action, request the hearing within 10 days of it, and put your request to continue services in writing. Continuation is not automatic, so you must ask for it.

Managed care (MCO) appeals in Nevada Medicaid

Nevada operates Medicaid managed care, so most recipients get their care through a health plan rather than directly from the state. The contracted Managed Care Organizations (MCOs) are Anthem Blue Cross and Blue Shield Healthcare Solutions, Health Plan of Nevada, Molina Healthcare of Nevada, and SilverSummit Healthplan, with LIBERTY Dental Plan of Nevada as the Dental Benefits Administrator (DBA).4 When your plan denies care, you appeal to the plan before you reach a state fair hearing. These rules come from the federal managed care regulations at 42 CFR Part 438.

Under 42 CFR 438.404, your plan must give you timely, written notice of an adverse benefit determination, including a termination, suspension, or reduction of a previously authorized service.7 That notice must tell you how to appeal, how to ask for an expedited appeal, and how to request that your benefits continue.

You have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal, which may be requested orally or in writing.5 A plan has only one level of appeal, and you must exhaust it before you can request a state fair hearing.

The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours of receiving it.8 Both the 30-day standard timeframe and the 72-hour expedited timeframe can be extended by up to 14 calendar days if you request the extension or the plan shows the state that more information is needed and the delay is in your interest. Ask for the 72-hour expedited track whenever waiting on the standard timeline could seriously jeopardize your life, health, or ability to regain function.

Once the plan upholds its denial, you may request a State fair hearing.5 If the plan fails to meet the notice and timing rules, its appeal is deemed exhausted, and you may go straight to a State fair hearing.7 After the plan's notice of resolution, the state must give you no fewer than 90 and no more than 120 calendar days to request that hearing, with the exact number set by the state.9

How to request a Nevada Medicaid fair hearing

In Nevada, fair hearing requests go to the Nevada Medicaid Hearings Unit, part of the Division Compliance section of the Division of Health Care Financing and Policy (DHCFP). The hearing itself is an Administrative Hearing conducted by the Nevada Department of Administration Hearings Office, before a neutral Hearing Officer, at no charge to you.4

An expedited Fair Hearing is available, with supporting medical documentation, when a standard hearing could jeopardize your life, health, or ability to attain, maintain, or regain maximum function.4 If your denial came from a managed care plan, remember that you must finish the plan's internal appeal first, unless the plan failed to meet its notice and timing rules.

Learn More

Find personalized help navigating a Nevada Medicaid appeal at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.