North Dakota Medicaid Appeals: Deadlines and Keeping Benefits

If your North Dakota 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.1,2 In North Dakota you have 30 days from the date your notice of action is mailed to request that hearing.3 A North Dakota Medicaid appeal runs through North Dakota Health and Human Services (ND HHS), which handles both eligibility appeals and fair hearings.

In This Guide

• What a North Dakota Medicaid appeal can challenge
• What are the deadlines to appeal North Dakota Medicaid?
• How to keep your benefits during a North Dakota Medicaid appeal
• Managed care appeals for BCBSND expansion members
• How to request a North Dakota Medicaid fair hearing
• Frequently Asked Questions

What a North Dakota Medicaid appeal can challenge

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 North Dakota's Medicaid plan to grant a hearing to anyone whose claim for medical assistance is denied or is not acted on with reasonable promptness, and 42 CFR 431.220 extends that right to anyone who believes the agency made an adverse determination.1

In North Dakota, that right belongs to any applicant or recipient who is dissatisfied with a Medicaid decision made by their county or human service zone or by the department, or whose application has not been acted on with reasonable promptness.3 In practice, you can appeal:

• An application denial (income, assets, household composition, or documentation)
• A termination or reduction of eligibility or of a covered service
• A reduction in authorized service hours, such as personal care
• A prior authorization denial or a level-of-care determination
• A managed care plan's denial, reduction, suspension, or termination of a service
• A failure to act on your application with reasonable promptness

The right reaches across the program, from the first eligibility decision to a mid-year change in your services.

What are the deadlines to appeal North Dakota Medicaid?

Three request windows apply in North Dakota, and they are not the same number.

The first is the request window of 30 days. Under N.D. Admin. Code 75-01-03-06(1), a request for a fair hearing on a Medicaid action must be filed within 30 days after the order or action you are dissatisfied with.3 Federal law at 42 CFR 431.221(d) sets the Medicaid fair-hearing request window at a reasonable time not to exceed 90 days from the date the notice of action is mailed, and a state may set its own window at or below that 90-day ceiling.5 North Dakota sets its Medicaid window at the shorter 30 days and reserves the 90-day window for Supplemental Nutrition Assistance Program (SNAP, food assistance) appeals.3 Read the deadline off your own notice and do not assume you have 90 days.

The second is the continuation window, which closes before the action takes effect. That window is what keeps your benefits flowing during the appeal, and it is earlier than the 30-day filing deadline. It is covered in the next section.

The third applies only in managed care: 60 days, then 90 to 120 days. If your denial came from the Medicaid Expansion managed care plan, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.6 After the plan resolves that appeal against you, the state must give you no fewer than 90 and no more than 120 calendar days from the date of the plan's notice of resolution to request a state fair hearing. Confirm North Dakota's own deadline with ND HHS rather than assuming you have the full 120.4

One more deadline protects renewals. If your coverage ended only because you did not return a renewal form on time, you do not have to reapply from scratch: under 42 CFR 435.916, if you submit the renewal form within 90 days after the termination date, the agency must reconsider your eligibility without a new application. 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 Dakota may offer the same window but is not required to, so ask your Human Service Zone.7

How to keep your benefits during a North Dakota Medicaid appeal

Keeping benefits during an appeal is called aid paid pending, and it is never automatic.

Under 42 CFR 431.230(a), if the agency sent the required advance notice and you request the hearing before the date 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 law or policy.2 North Dakota applies the same trigger: benefits continue during the appeal when the hearing request is filed within the timely-notice period, generally before the effective date of the action.3

Filing late has a specific cost. Under N.D. Admin. Code 75-01-03-08 and 75-01-03-09, if the request is filed after the timely-notice period, the human service zone or program will neither reinstate nor continue aid.3 The department's notice of adverse action must explain the circumstances under which assistance will be continued if a hearing is requested, so the deadline you need is printed on the notice itself.

Continuing benefits carries one risk worth knowing before you ask for it. If the hearing decision goes against you, 42 CFR 431.230(b) permits the agency to recover the cost of the services that were furnished solely by reason of the continuation. That means the services you would not have received had the action taken effect on schedule, not everything you were covered for while the appeal was pending.2 For most people the protection is still worth having, but ask ND HHS what it would seek to recover in your case before you decide.

If you file within the 30-day window but after the action has taken effect, your appeal is still valid, but your coverage will not continue while you wait for the decision.

Managed care appeals for BCBSND expansion members

Managed care in North Dakota Medicaid is limited to the Medicaid Expansion population: adults ages 19 to 64 with household income up to 138% of the federal poverty level (FPL). That group is enrolled with a single managed care organization (MCO), Blue Cross Blue Shield of North Dakota (BCBSND).3 If you are an Expansion enrollee and BCBSND denies a service, the appeal path has an extra step that traditional Medicaid does not.

Exhaust the plan's own appeal first. A state fair hearing becomes available only after you have received a notice of resolution in which BCBSND upholds its adverse benefit determination, or after the plan fails to meet the notice and timing requirements of 42 CFR 438.408(b)(1) and (2), in which case the appeal is treated as exhausted.3,4 Filing a state fair hearing before completing the plan's internal appeal gets the request dismissed.

The notice is what starts the clock. Under 42 CFR 438.404, BCBSND must give you timely, written notice of an adverse benefit determination. That notice must explain the determination and the reasons for it, and tell you how to appeal, how to request an expedited appeal, how to ask that benefits continue, and the circumstances under which you may be required to pay the cost of those continued services.8

The plan's own timelines are fixed by federal rule. You have 60 calendar days from the date on the determination notice to file the internal appeal, orally or in writing.6 BCBSND must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours, and either timeframe can be extended by up to 14 calendar days if you request it or the plan shows the state that more information is needed and the delay is in your interest.4 Ask for the expedited 72-hour track whenever waiting on the standard timeline could seriously jeopardize your health or ability to function.

How to request a North Dakota Medicaid fair hearing

ND HHS conducts its own Medicaid fair hearings through its Appeals Supervisor and Legal Advisory Unit under N.D. Admin. Code chapter 75-01-03. Unlike some states, it does not route them to a separate central administrative-hearings agency.3

You can file an appeal in more than one way. A request can be made verbally over the phone, or in writing by email, fax, or mail.3 The state's SFN 162 "Request for Hearing" form may be used but is not required. If you do not use the form, provide your name, your contact information, and the program decision or error you are appealing, and that is enough to start the appeal.3

Written appeals and hearing requests are directed to the ND HHS Appeals Supervisor and Legal Advisory Unit:3

• Mail: Appeals Supervisor, North Dakota Health and Human Services, State Capitol, Judicial Wing, 600 E. Boulevard Ave., Dept. 325, Bismarck, ND 58505-0250
• Phone: (701) 328-2311, toll-free (800) 472-2622, TTY 711
• Fax: (701) 328-2173
• Email: dhslau@nd.gov

Whichever method you use, keep a dated copy of what you send. The 30-day deadline runs from the date the notice was mailed, so file as soon as you can and request that your benefits continue if the action would cut or end coverage you have now.

Learn More

Find personalized help navigating a North Dakota 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.