Oklahoma Medicaid Appeals and Fair Hearings

If your Oklahoma Medicaid (SoonerCare) coverage was denied, cut, or terminated, you have the right to appeal and request a fair hearing, and you can often keep your benefits during the appeal.1,2 Oklahoma Medicaid appeals run through the Oklahoma Health Care Authority (OHCA), which holds the hearing before its own administrative law judge (ALJ). Two deadlines decide your case: how long you have to request a hearing, and the earlier deadline to keep your benefits flowing while you wait.3

In This Guide

• What You Can Appeal in Oklahoma Medicaid
• The Oklahoma Medicaid Appeal Deadlines That Decide Your Case
• How to Keep Your Benefits During an Oklahoma Medicaid Appeal
• SoonerSelect Managed Care (MCO) Appeals
• How to Request an Oklahoma Medicaid Fair Hearing
• Frequently Asked Questions
• Learn More

What You Can Appeal in Oklahoma Medicaid

Federal law guarantees every Medicaid applicant and beneficiary the right to a fair hearing before the state agency, and that right reaches any action that denies, reduces, or ends your coverage or services.1

In SoonerCare, that means you can appeal:

• An application or eligibility denial (income, assets, or documentation)
• A termination or reduction of eligibility or a covered service
• A reduction in previously authorized service hours, such as personal care or in-home supports
• A prior-authorization denial or a level-of-care determination
• A SoonerSelect health plan's denial, reduction, suspension, or termination of a service

The right runs across the whole program, so if an action changes what SoonerCare pays for or whether you qualify, you can ask an OHCA administrative law judge to review it.

The Oklahoma Medicaid Appeal Deadlines That Decide Your Case

Two deadlines govern an Oklahoma Medicaid appeal, and which one applies depends on whether your action came through the fee-for-service (FFS) side or through a SoonerSelect managed care plan.

Administrative appeals (FFS and eligibility): To appeal an OHCA action such as an eligibility denial or a prior-authorization decision, you file Form LD-1 within 30 calendar days of the date OHCA sends written notice. When OHCA sends no formal notice, the 30 days run from the date you knew or should have known the facts behind the appeal.3 Federal law lets a state set this window anywhere up to 90 days from the mailing date, and Oklahoma uses the shorter 30-day period, so read the deadline off your own notice rather than assuming 90.4

SoonerSelect managed care: If a SoonerSelect health plan denied your service, you have 60 calendar days from the date on the adverse benefit determination notice to file the plan's internal appeal.5,3 After the plan upholds its decision, you have 120 days from the date of the adverse benefit determination notice to request a state fair hearing through OHCA on Form LD-1S.3 Federal rules require the state to allow no less than 90 and no more than 120 calendar days measured from the plan's notice of resolution, while Oklahoma's rule counts its 120 days from the adverse benefit determination notice, an earlier date.6,3 Because the plan may take up to 30 calendar days to resolve a standard appeal, the time left after the plan's decision can be well under 120 days, so count forward from the date on the original denial notice rather than from the plan's answer.6

Renewal safety net: If SoonerCare ended your coverage only because you did not return a renewal form on time, you may not have to appeal at all. 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, Oklahoma may offer the same window but is not required to, so ask OHCA.7

How to Keep Your Benefits During an Oklahoma Medicaid Appeal

Keeping your benefits during an appeal, often called aid paid pending, is never automatic. You have to request it, and you have to request it in time.

Federal trigger: 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, your services continue until a decision is rendered after the hearing, unless the only issue is one of law or policy.2 The trigger is the action date on your notice, not a flat count of days.

If you miss the action date: A request filed after the action's effective date does not trigger continuation under 42 CFR 431.230. A separate rule, 42 CFR 431.231, lets the agency reinstate your services if you request the hearing not more than 10 days after the date of action, so a missed continuation deadline is worth raising rather than treating as final.2

In a SoonerSelect plan appeal: Your plan continues your benefits during the appeal when you file the appeal within 60 calendar days of the adverse benefit determination notice, the appeal involves ending, suspending, or reducing a service that was already authorized, the service was ordered by an authorized provider, the original authorization period has not expired, and you request continuation by the later of 10 calendar days after the plan sends its notice or the proposed effective date of the change.3

Carrying continuation into the state fair hearing: To keep your benefits running through the OHCA state fair hearing after the plan upholds its denial, you must request the hearing within 120 days of the adverse resolution notice and request continuation within 30 calendar days of it.3

One caution before you ask: Continued benefits are not automatically free if you lose. Under 42 CFR 431.230(b), when the agency's action is later sustained, it may recover the cost of the services furnished solely by reason of the continuation. That is narrower than everything you received while the appeal was pending, and it does not reach care you were entitled to anyway.2 On the SoonerSelect side, the plan's adverse benefit determination notice has to state the circumstances, consistent with state policy, under which you may be required to pay the costs of continued services, so read that paragraph of your notice before you decide.8

SoonerSelect Managed Care (MCO) Appeals

Most SoonerCare members now receive their benefits through SoonerSelect, in which the state contracts with a managed care organization (MCO), which Oklahoma calls a contracted entity (CE), or a dental benefit manager (DBM). The SoonerSelect medical health plans are Aetna Better Health of Oklahoma, Humana Healthy Horizons in Oklahoma, and Oklahoma Complete Health, which also runs the Children's Specialty Program.3

Exhaust the plan's appeal first: You must complete your plan's one internal appeal before OHCA will hold a state fair hearing. You have 60 calendar days from the date on the adverse benefit determination notice to file that appeal.5,3 The plan's written notice of an adverse benefit determination must explain your appeal rights, including how to ask for an expedited review and how to request that your benefits continue.8

How fast the plan must decide: The plan must resolve a standard appeal within 30 calendar days and an expedited appeal within 72 hours, and either timeframe may be extended by up to 14 calendar days if you request the extension or the plan shows the state agency that more information is needed and the delay is in your interest.6 Ask for the expedited track whenever waiting on the standard timeline could seriously jeopardize your health or your ability to regain function.

Then the state fair hearing: Once the plan upholds its denial, you may request a state fair hearing through OHCA on Form LD-1S, within 120 days of the adverse benefit determination notice.3 You may also request one when the plan fails to meet 42 CFR 438.408's notice and timing requirements for resolving your appeal, because the appeal is then deemed exhausted.6,5

How to Request an Oklahoma Medicaid Fair Hearing

In Oklahoma, SoonerCare appeals and state fair hearings run through OHCA, whose Office of Administrative Hearings holds the hearing before an OHCA administrative law judge (ALJ). There is no separate state tribunal outside OHCA.3

How you file depends on the kind of action:

• Administrative (FFS or eligibility) action: File Form LD-1 (Member Complaint/Grievance Form) within 30 calendar days of OHCA's written notice. OHCA will arrange assistance completing the form if you need it, and once it has your appeal it schedules the fair hearing.3
• SoonerSelect plan action: Appeal to your plan first, then file Form LD-1S (Request for State Fair Hearing) within 120 days of the adverse benefit determination notice, after the plan upholds its decision.3

Hearings default to telephone. If you want an in-person hearing, you must request it in writing on OHCA's Form LD-4.3

Learn More

Find personalized help navigating an Oklahoma 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.