North Carolina Medicaid Appeals and Fair Hearings

If your North Carolina Medicaid was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits while the appeal is pending. A North Carolina Medicaid appeal runs on strict deadlines: how fast you act decides both whether your case is heard and whether your services keep flowing in the meantime.

In This Guide

• Key Facts
• What You Can Appeal
• The Deadlines That Decide Your Case
• How to Keep Your Benefits
• Managed Care (MCO) Appeals
• How to Request a Fair Hearing
• Frequently Asked Questions
• Learn More

What You Can Appeal in North Carolina Medicaid

Federal law gives Medicaid applicants and beneficiaries the right to a fair hearing before the state. Under 42 CFR 431.220, North Carolina must offer a hearing to anyone who believes the agency acted erroneously, denied a claim for eligibility or for covered services, or did not act on a claim with reasonable promptness, as well as to managed care enrollees entitled to one under the federal managed care rules and to nursing facility residents who believe they are being wrongly transferred or discharged. The one stated exception: no hearing is required when the sole issue is a federal or state law that automatically changes benefits for some or all beneficiaries.4 In North Carolina, the Office of Administrative Hearings hears appeals of a determination to deny, terminate, suspend, or reduce a Medicaid service or an authorization for one. Eligibility decisions made by your county department of social services follow a separate route, covered in the deadlines section below.1

In practice, you can appeal:

• An application or eligibility denial (income, assets, household, or documentation)
• A termination of eligibility or of a covered service
• A reduction in a service, such as fewer authorized personal-care hours
• A suspension of a service you were already receiving
• A prior authorization denial or a limited authorization of a requested service
• A managed care plan's denial, reduction, suspension, or termination of a service

For managed care members, the same rights attach when the plan issues what the federal rules call an adverse benefit determination. The plan must send you written notice of that determination, and the notice must explain the decision and its reasons, your right to appeal and how to request a State Fair Hearing after the plan's own appeal, and your right to have benefits continue while the appeal is pending.2

North Carolina Medicaid Appeal Deadlines That Decide Your Case

The windows below are not all the same length, so read the date off your own notice rather than assuming one deadline covers every situation.

Eligibility decisions (county DSS): If your county department of social services denied your application or ended your coverage, request a hearing within 60 calendar days from the date the notice was mailed or given, or no later than 90 calendar days if you can show good cause. A local hearing is held at the county agency, with the county director or a designee presiding; appeals involving a disability determination go straight to a state hearing instead. If you disagree with the local hearing decision, you have 15 calendar days from its mailing to request a state hearing before a State Hearing Officer, unless you can show good cause. On this route, benefits continue until a hearing decision only in certain situations, so ask your county DSS whether yours qualifies.1

Service decisions (NC Medicaid Direct): If your coverage is fee-for-service NC Medicaid Direct and the decision denied, cut, suspended, or ended a service, complete the Medicaid Services Recipient Hearing Request Form enclosed with your adverse-decision notice and return it to the Office of Administrative Hearings by mail or fax within 30 days of the date the notice was mailed.1 Federal law sets the ceiling at 90 days from the mailing date, and North Carolina's 30-day window sits below that federal maximum.1 Do not assume you have the full 90 days. The 30 days also don't restart because the notice never reached you: if your address with DSS or SSA was out of date, or you didn't accept a notice sent by trackable mail, the time to appeal is not extended. But if the notice went to the wrong person or address, or Medicaid or its review vendor made some other error, a new notice with an updated date must be issued, which restarts the clock.1

Continuation window: A separate, earlier deadline decides whether your benefits keep flowing during the appeal. It is covered in the next section.

Managed care windows: If your denial came from a managed care plan, federal rules give you 60 calendar days from the date on the adverse benefit determination to file the plan's internal appeal.5 After the plan issues its written Notice of Resolution, you have 120 days from the date that notice was mailed to request a State Fair Hearing from the Office of Administrative Hearings.1 Federal law requires the state to allow no fewer than 90 and no more than 120 days for that request, and North Carolina uses the full 120.3

One more federal safety valve protects renewals. If your coverage ended only because you did not return a renewal form on time, 42 CFR 435.916 requires the agency to reconsider your eligibility without a new application if you submit the renewal form within 90 days after the termination date (a state may allow longer). That duty covers eligibility based on modified adjusted gross income (MAGI). If you qualify through age, disability, long-term care, a Medicare Savings Program, or the medically needy pathway, North Carolina may offer the same window but is not required to, so ask your county DSS.6

How to Keep Your Benefits During a North Carolina Medicaid Appeal

This protection has a name in North Carolina: Maintenance of Service (MOS). It applies when a continuing service is being reduced, terminated, or suspended, and how fast you appeal decides whether there is any gap in your care. The three deadlines below are the NC Medicaid Direct rules, and each one is measured against the hearing request form the Office of Administrative Hearings receives from you. Once in place, MOS lasts as long as you remain otherwise Medicaid eligible and don't give up the right, but it is not open-ended. NC Medicaid's 2011 appeal-rights document says it ends when a final agency decision upholds the original decision to reduce, terminate, or suspend the service. That document predates OAH's current procedure, in which the judge's Final Decision is the last administrative step, so ask NC Medicaid when MOS would end in your case.1 If you are in a managed care plan, read the managed care note at the end of this section before you count days.

Appeal within 10 days: Payment authorization for the service stays in place with no break in service.1

Appeal after 10 but within 30 days: Authorization is reinstated retroactive to the date the Office of Administrative Hearings receives your completed request form.1 Coverage is restored, though not without a gap. In both cases, payment is authorized at the level in place the day before the adverse decision or the level your provider requested, whichever is less.1

Appeal after 30 days: Maintenance of Service is not authorized when the appeal is filed more than 30 days after the notice was mailed, whether or not OAH accepts the late appeal. It is also not authorized if your provider asked to continue a service only after your current authorization had already expired; Medicaid treats that as a new request.1

The underlying federal rule is the same principle stated at the national level: under 42 CFR 431.230, when the agency has sent the required advance notice and you request the hearing before the action takes effect, your services continue until a hearing decision is rendered. The narrow exception requires both a finding at the hearing that the sole issue is one of federal or state law or policy and prompt written notice from the agency that services will be cut pending the decision. And if your services were cut without the required advance notice, federal rules require the agency to reinstate them if you request a hearing within 10 days of receiving the notice (receipt is presumed 5 days after the date on it) and the action did not result from applying federal or state law or policy.7

If you are in a managed care plan: the deadlines above are keyed to a hearing request filed with the Office of Administrative Hearings, and a Standard Plan member cannot file there until the plan's own appeal is finished.1 So ask the plan to continue your benefits when you file the internal appeal. Federal rules require the plan's adverse benefit determination notice to tell you that you have the right to have benefits continue while the appeal is pending and how to request that they continue.2 Federal managed care rules then set two 10-day clocks of their own. To keep benefits during the plan appeal, you must file the appeal and ask for continuation on or before the later of 10 calendar days after the plan sends its notice or the date the change is set to take effect; continuation also requires that the service was previously authorized, ordered by an authorized provider, and that the original authorization period hasn't run out. To keep benefits through the State Fair Hearing, you must request the hearing and continuation within 10 calendar days after the plan sends its Notice of Resolution. Taking the whole filing window keeps your appeal alive but not your services.3

Managed Care (MCO) Appeals: Appeal to Your Health Plan First

In North Carolina Medicaid Managed Care, a Standard Plan is a Prepaid Health Plan run by a managed care organization (MCO). As of 2026 the Standard Plans are AmeriHealth Caritas North Carolina, Healthy Blue of North Carolina, and UnitedHealthcare of North Carolina statewide, and Carolina Complete Health in Regions 3, 4, and 5. Standard Plans aren't NC Medicaid's only managed care arrangement: there is also the Children and Families Specialty Plan (Healthy Blue Care Together), the Behavioral Health I/DD Tailored Plans (Alliance, Partners, Trillium, and Vaya), and the EBCI Tribal Option, so if you're in one of those, don't assume you have no plan-level appeal.1 When a Standard Plan denies care, you appeal to the plan before you can reach the state hearing.

Exhaust the plan first: A member enrolled in a Standard Plan must first appeal to the health plan and complete the plan's reconsideration review; only after the plan issues its Notice of Resolution may you request a State Fair Hearing.1 There is one federal escape: if the plan fails to follow the notice and timing requirements of 42 CFR 438.408, you are deemed to have exhausted its appeal and may go to the State Fair Hearing without waiting.3

Internal appeal deadline: Federal managed-care rules give you 60 calendar days from the date on the plan's adverse benefit determination to file the internal appeal, which you can request orally or in writing. A provider or authorized representative can file it for you with your written consent, if state law permits. One caution for people with both Medicare and Medicaid: if you're in an integrated plan that covers both, different federal appeal rules apply, so follow the deadline on your plan's notice.5

How fast the plan must decide: Federal rules cap the plan's time at 30 calendar days for a standard appeal and 72 hours for an expedited one, counted from when the plan receives it, and within those caps the plan must decide as quickly as your health condition requires. Each deadline can be extended by up to 14 calendar days if you ask for the extension, or if the plan shows the state that it needs additional information and how the delay is in your interest. If the plan extends without your request, it must give you written notice of the reason within 2 calendar days and tell you that you can file a grievance if you disagree. If the plan misses these requirements, the deemed-exhaustion escape above applies and you can go to the State Fair Hearing.3 If waiting could harm your health, ask for the expedited track; the plan's notice must explain when an appeal can be expedited and how to request it.2

After the plan upholds its denial: Once the plan mails its Notice of Resolution, complete the State Fair Hearing Request Form that comes with it and return it to the Office of Administrative Hearings and to the managed care organization within 120 days of the date the Notice of Resolution was mailed.1

How to Request a North Carolina Medicaid Fair Hearing

A service appeal is not decided by the agency that denied you. It goes to the North Carolina Office of Administrative Hearings (OAH), not to NC Medicaid or the North Carolina Department of Health and Human Services. State law (N.C.G.S. § 7A-750) makes OAH an independent, quasi-judicial agency that supplies independent administrative law judges.1 Filing there correctly is what starts the clock on your hearing.

Where to file: OAH's address is 1711 New Hope Church Road, Raleigh, NC 27609; its phone is 984-236-1850 and its main fax is 984-236-1871.1 Recipient hearing requests are submitted by mail or fax using the request form enclosed with your notice.

How the process runs: OAH or the Mediation Network of North Carolina contacts every recipient appellant to offer mediation, and you can decline it and go to hearing. If you accept, know that a settlement reached there is legally binding, even if you're unhappy with it afterward. Hearings are by telephone unless you request an in-person hearing after you receive the Notice of Telephone Hearing; an in-person hearing is held in Raleigh unless you show hardship and the judge agrees to another location. NC Medicaid's 2011 appeal-rights document says the hearing process must be completed within 90 days of OAH's receipt of your completed form, but that is not a hard stop. If new evidence Medicaid hasn't reviewed comes in at the hearing or mediation, Medicaid may ask for more time, and if it does, the judge must pause the hearing for at least 15 and no more than 30 days so Medicaid can review it.1

If you lose before the judge: The Administrative Law Judge's Final Decision is not the last step. Either side can file a Petition for Judicial Review in the Superior Court of the county where you live, within 30 days after being served with a written copy of the decision, and a copy must go to OAH at the same time.1

What to bring: For a medical-necessity dispute such as a prior authorization denial or a cut in personal-care hours, ask the treating provider for a letter documenting why you need the service.

Learn More

Find personalized help navigating a North Carolina 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.