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 Appeals of Oklahoma Health Care Authority (OHCA) actions, and state fair hearings on SoonerSelect plan decisions, are heard by an OHCA 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 gives Medicaid applicants and beneficiaries the right to a fair hearing before the state agency when it denies a claim for eligibility or for covered services, changes the amount or type of your services, makes a prior-authorization decision, or fails to act on your claim with reasonable promptness. The one stated exception: the agency need not grant a hearing when the sole issue is a federal or state law requiring an automatic change that affects some or all beneficiaries.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
• A SoonerSelect health plan's denial, reduction, suspension, or termination of a service

OHCA's rule gives its administrative law judge jurisdiction over member appeals about the scope of services, covered services, enrollment and disenrollment, fee-for-service decisions including prior authorizations, eligibility determinations made by OHCA, and state fair hearing requests after a SoonerSelect plan appeal. That list does not name eligibility decisions made by Oklahoma Human Services (OKDHS), so if your aged, blind, disabled, or long-term-care eligibility decision came from OKDHS, don't assume the OHCA process applies; follow the appeal instructions on that notice.3

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 OHCA eligibility): To appeal an OHCA action such as an OHCA eligibility determination 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. OHCA's hearing rule and Form LD-1S count Oklahoma's 120 days from the adverse benefit determination notice, an earlier date, though OHCA's continuation rule refers to the adverse resolution notice instead; counting from the earlier notice is the reading that cannot make your request late.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 or requested information 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 (or a longer period the state elects), 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 the agency that sent your termination notice.7

How to Keep Your Benefits During an Oklahoma Medicaid Appeal

Keeping your benefits during an appeal, often called aid paid pending, turns on requesting in time. Don't assume it happens on its own: ask for continuation explicitly, and check the deadline on your notice.2

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 both halves of a narrow exception are met: the hearing determines that the sole issue is one of federal or state law or policy, and the agency promptly tells you in writing that services will be terminated or reduced pending the decision.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. And if the agency acted without the required advance notice, 42 CFR 431.231(c) says it must reinstate and continue your services until a hearing decision when you request a hearing within 10 days of receiving the notice (receipt is presumed 5 days after the date on it), unless the action resulted from applying federal or state law or policy.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. If you make a written hearing request within those 60 days but don't say whether you want continuation, OHCA's rule continues or reinstates services by default, unless you have exceeded the limit for the service or no provider ordered it.3

Carrying continuation into the state fair hearing: OHCA's rule says the plan continues or reinstates benefits if you request a state fair hearing within 120 days and continuation within 30 calendar days of the adverse resolution notice. But the same rule ends benefits already continued during the plan appeal if you don't request both the state fair hearing and continuation within 10 calendar days after the plan sends that notice. To keep services flowing without a gap, request both within 10 calendar days of the plan's adverse resolution notice.3,6

One caution before you ask: Continued benefits are not automatically free if you lose. For an OHCA action, 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

SoonerSelect members receive their benefits through a managed care health plan, which Oklahoma calls a contracted entity (CE), or a dental benefit manager (DBM). OHCA lists three SoonerSelect medical health plans: Aetna, Humana Healthy Horizons in Oklahoma, and Oklahoma Complete Health, alongside separate SoonerSelect dental plans and a separate Children's Specialty program.3

Check whether you're in SoonerSelect at all: OHCA's automatic-enrollment groups include children, low-income adults, pregnant women, and non-disabled adults ages 19 to 64. OHCA excludes, among others, dual eligibles (people with both Medicare and Medicaid), Medicare Savings Program enrollees, people with a nursing facility or ICF-IID level of care, people in a 1915(c) waiver, and people eligible on the basis of age, blindness or disability. If that describes you, you stay in your current SoonerCare program and the plan-appeal steps below don't apply; use the appeal route printed on your notice instead.3

Exhaust the plan's appeal first: You must appeal to your plan first, and you can request a state fair hearing through OHCA only after the plan sends notice upholding its decision, or after the plan's process is deemed exhausted (below). 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 decide as fast as your health requires, and federal rules cap the state's timeframe at 30 calendar days from when the plan receives a standard appeal and 72 hours for an expedited one. Either timeframe can be extended by up to 14 calendar days if you ask for the extension, or if the plan shows the state agency, to its satisfaction, that it needs more information and how the delay is in your interest. If the plan extends without your asking, it must give you written notice of the reason within 2 calendar days and tell you of your right to file a grievance if you disagree.6 If waiting could harm your health, ask for the expedited track; your plan's notice must explain when an appeal can be expedited and how to request it.8

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 follow 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, member appeals of OHCA actions and state fair hearings on SoonerSelect plan decisions are heard by an OHCA administrative law judge (ALJ). An eligibility decision made by Oklahoma Human Services (OKDHS) is not on the OHCA judge's list, so follow the appeal instructions on that notice.3

How you file depends on the kind of action:

• Administrative (FFS or OHCA 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 no later than 10 calendar days before the scheduled hearing date, a separate deadline from the one for filing the appeal.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.