The Appeals and Complaints Branch administers the processes that Medicaid members and providers can use to appeal Medicaid-related decisions.
The branch conducts activities to ensure Medicaid members have access to quality services. Appeals and Complaint Branch staff:
- Oversee External Independent Third-Party Reviews (EITPR). EITRP is used when a service or claim is denied, and the provider has exhausted the internal managed care organization (MCO) appeals process.
- Coordinate and manage administrative hearings. Medicaid members and providers can use this process to challenge decisions such as those that find a provider ineligible to deliver services or a member ineligible to enroll in Medicaid.
- Manage state fair hearings. Medicaid members and providers can use this process to challenge decisions that deny or reduce a person’s Medicaid services.