Other Appeals

I (or my representative) would like to appeal a Medicaid decision about a service (ie: therapy, pharmacy, nursing, personal aide, etc.).

Personal Information

Beneficiary First Name *

Beneficiary Last Name *

Address

City

State

Zip

Phone Number *

Phone Number

Medicaid ID

Household Number

Please list all beneficiaries appealing

Are you enrolled in an MCO?

Which one

Have you exhausted the appeals process with your MCO?

You must exhaust the internal appeals process with your MCO before you can appeal to the Office of Appeals and Hearings.

Do You Have a Representative?

Representative Information

First Name

Last Name

Address

City, State, Zip

Phone Number

FAX

Relationship to Applicant/Beneficiary

Documentation

Please state why or how you think the agency erred or why you are appealing.

Issue

Description

If you would like to attach the denial notice, authorized representative form/notice of appearance, or supporting documentation, please do so now. You will have an opportunity to do so later after your appeal is received.

Denial Notice

Files must be less than 8 MB.
Allowed file types: jpg jpeg png txt rtf pdf zip.

Additional Records/materials

Files must be less than 8 MB.
Allowed file types: jpg jpeg png txt rtf pdf zip.

Expedited Appeals

You can request an expedited appeal. This means your appeal will be resolved as quickly as possible instead of the standard 90-day timeframe. SCDHHS will grant or deny these requests as quickly as possible. If we deny your request to expedite, your appeal will follow the standard 90-day timeline.

While supporting documentation is not required, we encourage you to include any additional documents with the request for expedited review. SCDHHS will make its decision based on information available at the time of the request.

Expedite hearing?

Yes

I would like to request an expedited hearing.

Reason for Expedite Request

If Other

Please upload any additional documentation or fax to (803) 255-8206

Please save Microsoft Word documents as .PDF
Files must be less than 2 MB.
Allowed file types: pdf.

Accommodations

Do you or your representative require special accommodations?

Select Special Accommodations if Needed

If so, please let us know how we can assist you

Most hearings are held at the SCDHHS main office in downtown Columbia, where metered parking can be limited. Would you like us to reserve parking for you for purposes of the hearing?

Yes/No

The Office of Appeals and Hearings will make every effort to obtain and reserve parking for hearing participants. However, reserved parking is not guaranteed. You will be notified if we are unable to reserve parking for you.

Internal use only

Telephone Appeal

Appeal taken by the Healthy Connections Member Contact Center via telephone

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Other Appeals

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