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Eligibility Appeals

This is a denial of an initial application for Medicaid or nursing home benefits. For questions regarding Eligibility Appeals please read the Eligibility Appeals FAQs below.

Eligibility Appeals

Provider Appeals

This is a denial of claim for services rendered by a provider after any applicable reconsideration process has occurred. It also is an appeal from a determination from the Office of Program Integrity regarding an overpayment, suspension, or termination of a provider.

Provider Appeals

Other Appeals

This is a denial of a request for services by a Medicaid Member before the services were provided.

Prior to filing an appeal on behalf of a Medicaid Member, you must have legal authority to do so, or have a completed Form 1282 signed by the Member granting permission to act on their behalf.

Other Appeals

FAQs

Please view the frequently asked questions (FAQs) related to the appeals process for information that can help you choose the right appeal process. The contents of the FAQs are for informational purposes only, and answers may vary by situation or hearing officer. Please read any orders or other communications received from a hearing officer carefully and follow any instructions given.

Appeals and Hearings FAQs

What is an appeal?

An appeal is asking for a hearing because you do not agree with a decision the South Carolina Department of Health and Human Services (SCDHHS), a Managed Care Organization (MCO), or another party acting on behalf of the agency has made. The hearings that are held are often referred to as "fair hearings."

An appeal is not a claim review or claim reconsideration process. Providers should exhaust their options through the SCDHHS Provider Service Center at 888-289-0709 or, if applicable, through the agency's Claim Reconsideration Process.

You should state why and what you are appealing or why you think the decision made is erroneous. You should include a copy of the notice you received, keeping the original for your records. Additionally, you should include your full contact information (name, address, phone number, email, Medicaid number, etc.) so we can contact you.

You can also include copies of additional documentation you want the hearing officer to review (ie: medical records, bank statements, etc.). However, you will have an opportunity later in the process and during the hearing to introduce those documents.

You may also request continued benefits or services if you request continued services within ten days (10) of the date on the notice.

What is a fair hearing?

A fair hearing is an in-person proceeding conducted by a hearing officer of the Office of Appeals and Hearings. The parties and hearing officer will meet at a set time and place for the hearing. During the hearing, the hearing officer listens to your explanation as to why you do not agree with the action taken by SCDHHS, the MCO, or another party acting on the agency's behalf. The hearing officer will also listen to the representative for the other party explain the action taken on your case. Both sides can ask questions of the other party's witnesses. The hearing officer can also ask the witnesses questions. After the hearing, the hearing officer will issue a written decision in the case.

Hearings are not held telephonically.

Where is a fair hearing held?

Most hearings are held at Jefferson Square, 1801 Main Street, Columbia, SC 29201. Occasionally, hearings may be scheduled for county eligibility or Community Long Term Care (CLTC) offices or other locations. You may request a different location for the hearing. The location of the hearing will be determined by the hearing officer.

What is a hearing officer?

A hearing officer is a neutral third party that presides over the appeal. The hearing officer guides the proceeding, sending letters and orders to the parties. The hearing officer also presides over the hearing and issues a final order in the appeal.

A hearing officer is not a representative or advocate for any party at the proceeding, and he or she cannot provide legal or other advice to either party.

When can I appeal?

The following are some of the situations in which you can ask for an appeal (not an exhaustive list):

You are denied eligibility.
Your benefits or services are reduced, terminated, or suspended.
The agency or another party (MCO, South Carolina Department of Disabilities and Special Needs [SCDDSN], etc.) denies your request for benefits or services.
Your request for prior authorization is denied.
A decision on your application or request for benefits has not been made in a timely manner.
You receive notice that the nursing home where you reside plans to discharge or transfer you against your wishes.

How do I appeal?

You should carefully read the notice or denial you receive. It will contain instructions on how to appeal.

To appeal a Medicaid eligibility decision, state what and why you are appealing and include a copy of the notice you received.

You can submit this information in the following ways:

Online. You will receive an electronic confirmation via email after submitting an appeal.
Fax to 803-255-8206 or 803-255-8251
Mail to SCDHHS, PO Box 8206, Columbia, SC 29202. Attn: Eligibility Appeals
Email to eligappeals@scdhhs.gov
Telephone 888-549-0820

If you are enrolled in a Managed Care Organization (MCO), you should contact your health plan and work through its internal appeal process before filing an appeal with the Office of Appeals and Hearings.

If you are enrolled in waiver services through SCDDSN, you should complete its reconsideration process before filing an appeal with the Office of Appeals and Hearings.

For other appeals, please state what and why you are appealing (why you think the decision made or action taken is wrong). Please include a copy of the notice or denial you received with your letter and be sure to include complete contact information for you and your representative (if you have one). Please submit the appeal one of the following ways:

Online. You will receive an electronic confirmation via email after submitting an appeal.
Fax to (803) 255-8206
Mail Office of Appeals and Hearings PO Box 8206 Columbia, SC 29202
Email to appeals@scdhhs.gov

Can I ask for my hearing to be considered quickly?

A beneficiary may request an expedited appeal. SCDHHS will grant or deny these requests as expeditiously as possible. If we grant your request to expedite, your appeal will be resolved as expeditiously as possible instead of the standard 90-day timeframe. If we deny the request to expedite, the appeal will follow the standard 90-day timeframe.

SCDHHS may grant expedited review if we determine the standard appeal timeframe could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function. SCDHHS may consider, among other facts:

The medical urgency of the beneficiary's situation.
Whether a needed procedure has already been scheduled.
Whether a beneficiary is unable to schedule a needed procedure due to lack of coverage.
Whether other insurance will cover most of the costs of the requested treatment.

You may request an expedited appeal at the same time you file your appeal request or after you file an appeal. Please state you are requesting an expedited appeal and explain why. Requests can be filed on the Appeals website (www.scdhhs.gov/appeals), by fax, email, or mail.

To avoid delays in the process, please submit any supporting documentation with the request for expedited review or immediately thereafter. While supporting documentation is not required, SCDHHS will make its determination based on the information made available at the time we consider the request.

Who is an Eligibility Respondent Coordinator?

Eligibility appeals are routed to the Eligibility Respondent Coordinator (ERC), who will review the appeal request and determination. In the case of caseworker or other error or upon the receipt of more information, the ERC may be able to resolve your appeal request without a hearing. If the ERC can resolve the case, you will be notified. If the case cannot be resolved, the ERC will send you and the hearing officer a copy of the Eligibility Appeal Summary. This summary includes all information about the eligibility determination that was made and the appeal. It can include supporting policy, any documents submitted with the application, the application itself, and other documents. Once the hearing officer receives the Eligibility Appeal Summary, he or she will continue with the appeal.

How long do I have to appeal?

You should carefully read the notice or denial you receive. It will contain instructions on how long you have to appeal. Some notices will give you thirty (30) days from the date of the notice. Other notices give you thirty (30) days from the day you receive the notice.

MCOs may have their own appeal times and procedures. Please review the notice you received carefully.

Can I ask for my services or benefits to continue?

New services cannot be started. However, you may request continued benefits or services if you do so within ten days (10) of the date on the notice. Your services or benefits will continue during the appeal process. Any disputed benefits or services you receive during the appeal process may have to be paid back if the hearing officer rules the agency, MCO, or other party making the decision was correct.

Can someone ask for an appeal for me?

Yes, you may have a representative appear on your behalf for the appeal. You can also represent yourself.

Do I have to hire an attorney?

No, an attorney is not required. However, you may hire an attorney if you choose to do so. The attorney should file a notice of appearance with the hearing officer as soon as possible.

Can I contact the hearing officer?

Yes, you may contact the hearing officer about procedural issues such as scheduling matters, questions about the appeals process, requests for an extension, or to withdraw an appeal. However, the hearing officer cannot discuss the substantive issues of the appeal with you without the other parties also on the communication (email, phone call, etc.). Speaking to the hearing officer about issues in the appeal without having all the parties involved is called ex parte communication. Ex parte communication is not allowed. The parties may speak to each other at any time without the hearing officer's involvement.

You can contact the Office of Appeals and Hearings at (803)898-2600 or (800)763-9087.

Can I receive communication and documents from the Appeals Office or Eligibility Respondent Coordinator s electronically?

Yes, you can elect to receive all documents via email. This option is available when you file appeals on the Appeals website. You can also indicate you would like to receive documents electronically by fax, email, or mail.

The Appeals Office and/or Eligibility Respondent Coordinator will send you a written confirmation if you elect to receive correspondence electronically. We will also send a test message to your email address and ask you to confirm you received it.

If the Appeals Office or ERC sends a message to you electronically and it does not bounce back as undeliverable, it is presumed to have been delivered.

If it bounces back as undeliverable, we will try to send it to the designated email address one more time. If it is returned as undeliverable again, we will place a hard copy of the correspondence or Order in the mail to you. Please be sure to provide an up-to-date and working email address.

Do you need special accommodations?

You may need accommodations in order to complete the appeals process. For example, you may need a translator, interpreter, a Braille form, handicap-accessible parking, or assistance with transportation. If you require special accommodations, please contact the Office of Appeals and Hearings at (803)898-2600 or (800)763-9087 so that we may assist you.

What is a Petitioner?

A Petitioner is the person filing the appeal or the person on whose behalf an appeal is filed.

What is a Respondent?

The Respondent is the party whose determination is appealed. It is often SCDHHS, an MCO, or a nursing home.

What is a Pre-Hearing Conference Order?

A Pre-Hearing Conference Order is often issued at the beginning of an appeal. It generally requires the appealing party, the Petitioner, to contact the Respondent, the agency or other party making the determination. The conference between the parties can be held in person, but it is most often conducted over the phone.

After the conference is held, both parties must then provide a summary to the hearing officer of the issues discussed and what issues remain outstanding. The Petitioner must also indicate if they want to move forward with a hearing. If the parties settled the matter, the Petitioner should indicate if they want to withdraw the appeal request.

As with all orders and communications received from the hearing officer, please carefully review the Order and follow all instructions. Failure to do so may result in dismissal of your appeal.

Who will be present at my hearing?

The hearing will include at least the following:

The hearing officer.
The Petitioner and/or their representative.
A representative from SCDHHS or the other organization making a determination. Others present may include:
Any witnesses either party brings to testify.
Observers, such as family members or other hearing officers, if the parties do not object to the observers' attendance, and their attendance does not otherwise disrupt the proceeding.

What happens at the hearing?

Hearings have a more relaxed environment than courtrooms you see on TV or in movies. Typically, the hearing officer, the parties, and any witnesses meet around a table in a conference room.

Both parties will be given an opportunity to present an opening statement. Then, the Petitioner is given a turn to speak and present its witnesses and arguments. The Respondent is then allowed to cross-examine the Petitioner's witnesses. Then the Respondent is given its turn to present its witnesses and arguments, with the Petitioner then being allowed to cross-examine those witnesses.

Typically, the Petitioner goes first in presenting its argument and case. However, when the Petitioner is not represented by an attorney, the hearing officer typically asks the agency or Respondent to go first. The hearing officer will determine the order of presentation. At the conclusion of the hearing, each party is given an opportunity to make a closing statement.

A decision will not be made the day of the hearing.

When will I get the order or decision from the hearing officer?

There is no set timeframe for receiving the order or decision from the hearing officer. The timeframe can depend on several factors: how much evidence needs to be reviewed, whether the parties submit additional evidence after the hearing, and the difficulty of the type of case, among others.

Ordinarily, beneficiary appeals should be concluded within 90 days of filing. The 90 days can be affected by requests for extension by the parties, requests to supply additional information to the hearing officers, and difficulty scheduling a hearing. There is no equivalent deadline for provider appeals. In all instances, the hearing officers strive to issue timely and thorough decisions.

You will receive the final order via certified mail. Please be sure to accept or retrieve certified mail when delivered or when you receive notice of it.

Can I appeal the hearing officer's decision?

Yes. You may appeal to the Administrative Law Court. Directions on how to contact and begin an appeal to the ALC are contained within the cover letter sent with the hearing officer's order. Please be aware that appeals must be filed with the ALC within thirty (30) days of the receipt of the hearing officer's order. For more information about appealing to the ALC visit the ALC website or call (803) 734-0550.

Eligibility Appeals FAQs

What is an appeal?

What is a fair hearing?

Hearings are not held telephonically.

Where is a fair hearing held?

What is a hearing officer?

A hearing officer is not a representative or advocate for any party at the proceeding, and he or she cannot provide legal or other advice to either party.

When can I appeal?

The following are some of the situations in which you can ask for an appeal (not an exhaustive list):

You are denied eligibility.
Your benefits or services are reduced or terminated.
Your eligibility is terminated.
A request for benefits or services is denied.
A decision on your application or request for benefits has not been made in a timely manner.

How do I appeal?

You should carefully read the notice or denial you receive. It will contain instructions on how to appeal.

To appeal a Medicaid eligibility decision, state what and why you are appealing and include a copy of the notice you received.

You can submit this information in the following ways:

Online
Fax to (803) 255-8251
Email to appeals@scdhhs.gov
Mail to SCDHHS, PO Box 8206, Columbia, SC 29202. Attn: Eligibility Appeals
- A request for a fair hearing by mail is considered filed if postmarked by the 30 calendar day following receipt of this notification.
In Person - Hand deliver your written appeal request to a Health Connections Medicaid (SCDHHS) county office or visit the county office to tell us verbally that you would wish to appear. Click here to find a county office or call (888) 549-0820.

Can I ask for my hearing to be considered quickly?

The medical urgency of the beneficiary's situation.
Whether a needed procedure has already been scheduled.
Whether a beneficiary is unable to schedule a needed procedure due to lack of coverage.
Whether other insurance will cover most of the costs of the requested treatment.

Who is an Eligibility Respondent Coordinator?

How long do I have to appeal?

You should carefully read the notice or denial you receive. It will contain instructions on how long you have to appeal. Some notices will give you 30 days from the date of the notice. Other notices give you 30 days from the day you receive the notice.

What should I include in my appeal letter?

You can also include copies of additional documentation you want the hearing officer to review (ie: bank statements, insurance policies, etc.). However, you will have an opportunity later in the process and during the hearing to introduce those documents.

You may also request continued benefits or services if you request continued services within 10 days of the date on the notice.

Can I ask for my services or benefits to continue?

New services cannot be started. However, you may request continued benefits or services if you do so within 10) of the date on the notice. Your services or benefits will continue during the appeal process. Any disputed benefits or services you receive during the appeal process may have to be paid back if the hearing officer rules the agency, MCO, or other party making the decision was correct.

Can someone ask for an appeal for me?

Yes, you may have a representative appear on your behalf for the appeal. You can also represent yourself.

Do I have to hire an attorney?

No, an attorney is not required. However, you may hire an attorney if you choose to do so. The attorney should file a notice of appearance with the hearing officer as soon as possible.

Can I contact the Eligibility Respondent coordinator?

Yes, you may contact the Eligibility Respondent Coordinator at the contact information listed above.

Can I contact the hearing officer?

You can contact the Office of Appeals and Hearings at (803)898-2600 or (800)763-9087.

Can I receive communication and documents from the Appeals Office or Eligibility Respondent Coordinator s electronically?

If the Appeals Office or ERC sends a message to you electronically and it does not bounce back as undeliverable, it is presumed to have been delivered.

If it bounces back as undeliverable, we will try to send it to the designated email address one more time. If it is returned as undeliverable again, we will place a hard copy of the correspondence or Order in the mail to you.

Please be sure to provide an up-to-date and working email address.

Do you need special accommodations?

What is a Petitioner?

A Petitioner is the person filing the appeal or the person on whose behalf an appeal is filed.

What is a Respondent?

The Respondent is the party whose determination is appealed. It is often SCDHHS, an MCO, or a nursing home.

What is a Pre-Hearing Conference Order?

As with all orders and communications received from the hearing officer, please carefully review the Order and follow all instructions. Failure to do so may result in dismissal of your appeal.

Who will be present at my hearing?

The hearing will include at least the following:

The hearing officer.
The Petitioner and/or their representative.
A representative from SCDHHS or the other organization making a determination. Others present may include:
Any witnesses either party brings to testify.
Observers, such as family members or other hearing officers, if the parties do not object to the observers' attendance, and their attendance does not otherwise disrupt the proceeding.

What happens at the hearing?

Hearings have a more relaxed environment than courtrooms you see on TV or in movies. Typically, the hearing officer, the parties, and any witnesses meet around a table in a conference room.

A decision will not be made the day of the hearing.

When will I get the order or decision from the hearing officer?

You will receive the final order via certified mail. Please be sure to accept or retrieve certified mail when delivered or when you receive notice of it.

Can I appeal the hearing officer's decision?