If you file an appeal for the denial of a service through Medicaid, you may be directed to participate in Medicaid Mediation. This is the first step in the Medicaid appeals process. Participation in Medicaid Mediation is voluntary.
Please note: the only way to use Medicaid Mediation is to file an appeal for denial of a Medicaid service with the Office of Administrative Hearings.
Medicaid provides health coverage for eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. For more general information about Medicaid, visit www.medicaid.gov.
About Medicaid Mediation
What is Medicaid Mediation?
After filing an appeal for the denial of a service through Medicaid, you may receive a letter or phone call informing you that you have been referred to Medicaid Mediation. During the Medicaid Mediation process, a conversation, frequently by phone, occurs between the Medicaid recipient (or their representative) and a staff member of the Department of Health and Human Services in the presence of a trained mediator. Medicaid Mediation is an informal conversation with a non-judgmental mediator to help clarify questions and ensure that everyone has the opportunity to share relevant information. Medicaid Mediation is the first step in the appeal process for Medicaid benefits.
How does Medicaid Mediation work?
After receiving a referral from the state, one of The Mediation Center’s team members will contact you to ask if you’d like to participate. Participation is voluntary. Since there is a limited time-window in which the Medicaid Mediation can occur, we appreciate your scheduling flexibility so that we can meet the required deadline for this stage of the appeal process.
Medicaid Mediation usually takes place on the telephone. In some cases, we may be able to arrange for the Medicaid Mediation to take place in-person. During the mediation, the Medicaid recipient or their representative meets with someone from the Department of Health and Human services. This person has expertise in the area of health care related to the appeal.
A neutral mediator is also on the call. The mediator’s role is to explain the process, improve all parties’ understanding of the situation, and ensure that the conversation is productive. The mediator does not make suggestions or decide the outcome. The mediator is not acting as a judge of the appeal.
How long does a Medicaid Mediation last?
Generally, each mediation lasts between 30 minutes to one hour.
How much does Medicaid Mediation cost?
Medicaid Mediation is fully funded by the State of North Carolina. Medicaid recipients never pay for Medicaid Mediation.
What do I need to bring with me to participate in a Medicaid Mediation?
While presenting evidence is not required, it can be useful to have information related to the appeal with you during the conversation as a point of reference. Relevant information includes comments or notes from your doctor, dates of procedures, medications you take, etc.
Can I bring someone with me?
If there are other people you feel should participate, such as your lawyer, doctor, caseworker, or friend, please let us know when we are scheduling so that we can find a time that works for everyone. It is especially important to let us know beforehand if you will have a lawyer present.
Why should I participate in Medicaid Mediation?
The purpose of mediation is to see if the people involved can work out a workable solution for all parties. You do not have to reach an agreement during Medicaid Mediation. However, even you do not reach an agreement, the Medicaid Mediation provides more information about why the service was denied and how to proceed.
If you are satisfied with the outcome, you can choose to withdraw your appeal and you will not need to continue to a hearing.
If you are not satisfied with the outcome of a Medicaid Mediation, you can choose to continue on with your appeal. The next step of the Medicaid appeal process is a hearing with an Administrative Law Judge. The judge will hear from both parties who participated in the Medicaid Mediation before making a decision about the appeal.
To learn more about our Medicaid Mediation services, call our Community Mediation Coordinator at(828) 251-6089 ext. 214 or email firstname.lastname@example.org.