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Filing an Appeal

How will I find out if services are denied or limited? What can I do if my doctor asks for a service for me/my child that’s covered, but MHS Health Wisconsin denies or limits it?

MHS Health will send you a letter if a requested service is denied or limited. If you disagree with the decision, you may file an appeal.

When do I have the right to ask for an appeal?

You have the right to appeal an MHS Health decision if Medicaid covered services are denied based on lack of medical need. MHS Health's denial is called an "action" or "adverse determination." You can appeal the action if you think MHS Health:

  • Is stopping coverage for care you think you/your child needs
  • Is denying coverage for care you think should be covered
  • Has not paid a hospital bill you think we should pay
  • Limits a request for a covered service

You, a doctor, or someone else acting on your/your child's behalf can appeal an action.

Can someone from MHS Health help me file an appeal?

The MHS Health Member Services Advocate can help you file an appeal. Call toll free at 1-800-547-1647 and ask for an advocate.

What are the timeframes for the appeals process?

You will have ninety (90) days from the date of the denial letter to appeal the decision. MHS Health will acknowledge your appeal within ten (10) days of receipt, and complete the appeal within thirty (30) days. This process can be extended up to fourteen (14) days. If more time is needed to gather facts about the requested service, you will receive a letter with the reason for the delay.