Making an Appeal

When your loved one receives a denial for a program or service, there is generally an appeal procedure that must be completed in writing by the person who has been denied. Below you will find common appeal procedures and forms for services and supports your loved one may need. 

Virginia Medicaid

What is an appeal?

An appeal is a written or verbal request for a fair hearing. This hearing is conducted by an impartial hearing officer from the Department of Medical Assistance Services Appeals Division.

What are my rights to appeal a decision by Medicaid?

You have the right to request an appeal of any action related to initial or continued eligibility for Medicaid. This includes: 

  • Denial of an application for Medicaid coverage; 

  • Denial, suspension, reduction or termination for a medical service or benefits as a whole; 

  • Effective date of Medicaid coverage; 

  • Delayed processing of your Medicaid application; 

  • A decision that benefits have been paid in error and must be repaid;

  • The amount of a Medicaid spend-down; 

  • The amount of a patient pay obligation;

  • Medicaid repayment from an estate of a person who has died; and/or

  • Any other action that impacts receipt of medical services

Who can file an appeal?

  • Parent or legal guardian for a minor child; or

  • Spouse, family member, guardian or authorized representative of an incapacitated adult (documentation of guardianship or authorized representation must be included in the appeal)

How do I file an appeal?

You may file an appeal by email, fax, mail, in person or by phone.

  • Email your appeal request to DMAS at appeals@dmas.virginia.gov. Be sure to request receipt that the email has been received through your email provider. 

  • Fax your appeal request to DMAS at (804) 452-5454

  • Mail your appeal request to: Appeals Division, Department of Medical Assistance Services, 600 E. Broad Street, Richmond, VA 23219​

  • You may deliver your appeal in person to the address listed above

  • Call DMAS at (804) 371-8488 TTY 1-800-828-1120

Click here to download the required appeal form

When must I file an appeal by?

Appeals must generally be completed within 30 days of the decision by DMAS. We recommend you file an appeal immediately and document any correspondence with the agency. 

What happens to Medicaid benefits when you appeal?

You may request to have coverage continued during the appeal process.

What happens after I file an appeal?

You will receive a letter from DMAS acknowledging receipt of your appeal. The appeal request will be reviewed to see if a hearing will be granted. Once the Appeals Division determines if a hearing will be granted, you will be notified in writing of the date, time and location of the hearing. 

What happens at a hearing?

The hearing is an informal procedure. The hearing officer will begin the hearing and state the reason for the hearing. Each side will be able to present evidence. You can ask questions of the witnesses for the agency. In addition, you and the agency will be able to provide closing remarks.

Who can represent me at a hearing?

​You can represent yourself at the hearing. You can also have a patient advocate, friend or relative represent you. 

Who will be at the hearing?

  • The hearing officer; 

  • The agency representative; and

  • You, the person appealing

What should I bring to the hearing? Can I submit evidence before the hearing?

​You should bring any evidence you have regarding the denial and why you believe it is incorrect. Bring letters, statements and any documentation to support your case. If you wish to submit your evidence before the hearing, you may do so by mailing the documents to:

 

Department of Medical Assistance Services

Appeals Division

600 E. Broad Street

Richmond, VA 23219

What happens after the hearing?

​The hearing officer will review the testimony and the evidence and issue a written decision. This is completed within 90 days from the date you filed an appeal. 

What if I disagree with the outcome of the hearing?

You may appeal to the Circuit Court using the process explained in the written decision.

Additional appeals links

Department of Aging & Rehabilitative Services Appeals

What issues can be appealed with DARS?

  • Applicant eligibility for vocational rehabilitative services; 

  • Nature, contents or scope of the Individualized Plan for Employment (IPE); 

  • Quality of counseling services; 

  • Delivery or quality of other vocational rehabilitation services, including pre-employment transition services, transition services to students and youth with disabilities, and semi-annual and annual review of individuals known to DARS to be in extended employment earning less than minimum wage; 

  • Cost of services, including DARS funding, refusal to pay for certain services, fee schedules and maximum allowances; and

  • Termination of a service, case or dismissal from Woodrow Wilson Rehabilitation Center

Client Assistance Program 

The Client Assistance Program helps persons seeking information, applying for services, or receiving services from vocational rehabilitation (VR) services from the Department of Aging and Rehabilitative Services (DARS). The program is administered by Disability Law Center of Virginia and are available at no cost to clients and students or youth receiving pre-employment transition services. 

Appeal Procedure: Informal Administrative Review

If a client has an issue with a DARS determination or other concern, he or she may ask for a supervisor to conduct an Informal Administrative Review, or IAR within 60 CALENDAR days of the most recent communication regarding the concern or issue. The IAR must be requested in writing. 

 

Within 10 BUSINESS days after receiving the IAR, a written decision must be made to the client and the counselor in writing that includes the following: 

  • Who requested the IAR; 

  • The date; 

  • The issue addressed; 

  • The decision reached through the IAR; 

  • The rationale for the decision, including the citation of any applicable laws, regulations or policies; and

  • The right to proceed to a hearing, mediation or request services from the Client Assistance Program

Appeal Procedure: Mediation

Mediation is a voluntary way to resolve concerns and appeal decisions. This is done in coordination with, not in place of the counselor and/or case manager in resolving case issues. The issue must have been communicated to the counselor or supervisor within the last 60 calendar days. Other important facts regarding mediation include:

  • The mediator will allow the client or recipient of services to be represented by an attorney or advocate; 

  • The client MAY be reimbursed for transportation costs to and from the mediation session; 

  • DARS will pay for the cost of mediation; and

  • Each party will have the opportunity to present evidence that supports their position

Any agreement reached by the parties during mediation will be documented in a written mediation statement and shall be considered valid when signed and is consistent with both state and federal regulations. 

Appeal Procedure: Hearing

Within 60 calendar days after mediation has ended without a resolution, DARS may request a hearing on the issues and/or concerns. Additionally, the client may request a hearing, using the RS-9, Request for Hearing form. Once a written hearing request is received, the request is immediately forwarded to the vocational rehabilitation appeals coordinator in the Policy and Legislative Affairs Division for processing. Other important notations include:

  • The client or service recipient may be represented by counsel or other advocate, or may be referred to the Client Assistance Program; 

  • Transportation costs for the client or service recipient may be reimbursed; 

  • Substantive issues will not be discussed off the record; 

  • Within 10 CALENDAR days of accepting the case, the hearing officer will notify the client or service recipient of the hearing date, time and place of the hearing as well as a copy of his or her rights;

  • A pre-hearing conference may be held to clarify the issues to be addressed to streamline the meeting; 

  • Witnesses and exhibits may be offered by both parties;

  • All hearings are closed to the public unless a request is granted to make it public; 

  • Testimony is given under oath with the hearing officer; and

  • A written hearing decision shall be issued within 30 CALENDAR days after the hearing to the client, service recipient and DARS commissioner. 

Click the document below for a copy of the hearing request form. 

Appeal Procedure: Administrative Review of Hearing Decision

Within 20 CALENDAR days after the hearing decision date, the client or service recipient may request an Administrative Review of the Hearing decision. The request must be:

  • Written; 

  • State the specific decision(s) to be reviewed

  • Be submitted to the VR appeals coordinator 

Social Security Appeals

Levels of Appeals

Reconsideration

Reconsideration is a complete review of your Social Security claim by someone who was not involved in the original decision. In most cases, you do not need to be present for a reconsideration review. 

Click here for the form requesting reconsideration.

Hearing by an administrative law judge

If you disagree with the reconsideration decision, you may next request a hearing by an administrative law judge. Again, this will be reviewed by someone who did not take part in your original claim. You may be asked to prepare and submit evidence to support your claim prior to the hearing. After the hearing, the judge will make a decision based on the information and evidence in your case. You will receive a letter with a copy of the judge's final decision by postal mail. 

Click here for the form to request a hearing by an administrative law judge.

Review by the Appeals Council

If you disagree with the hearing decision, you may next request a review by the appeals council. Not all reviews by the appeals council will be considered. If your review is denied, you will receive a letter through postal mail explaining the reasons the review was denied. If your review is accepted, you will received a letter and a copy of the order. 

Click here for the form to request a review by the Appeals Council. 

Federal Court Review

If you disagree with the decision of the Appeals Council, you may file a lawsuit in a federal district court. All instructions on how to file this lawsuit will be included in the letter you receive from the appeals council. 

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© 2023 by The Arc of Northern Shenandoah Valley. 

Tel: 540-692-9650

Email: shenvalleyarc@gmail.com

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