Pennsylvania Medicaid Denied? Appeal Through DHS, HealthChoices MCOs, and Fair Hearing

Pennsylvania's Medicaid program, called Medical Assistance (MA), covers millions of low-income residents including children, families, pregnant women, adults with disabilities, and seniors. The program is administered by the Pennsylvania Department of Human Services (DHS) and delivered through managed care organizations (MCOs) under the HealthChoices program. If your claim was denied, you have the right to appeal — and Pennsylvania's process includes both internal MCO appeals and formal DHS fair hearings.

How Pennsylvania Medicaid Works

Most Medical Assistance enrollees receive care through a HealthChoices MCO. The MCOs vary by geographic zone:

• Aetna Better Health of Pennsylvania
• Geisinger Health Plan
• Keystone First (Independence Blue Cross)
• UPMC for You
• Community HealthChoices (for older adults and people with physical disabilities needing LTSS)
• PA Health & Wellness (Centene)

Pennsylvania also runs CHIP (Children's Health Insurance Program), which covers uninsured children who don't qualify for Medical Assistance. CHIP uses similar MCOs and the same appeals framework.

Why Pennsylvania Medicaid Claims Get Denied

Common reasons HealthChoices MCOs deny claims or Prior Authorization Denied: How to Appeal" class="auto-link">prior authorizations include:

• Medical necessity: The MCO determines the service doesn't meet its clinical criteria
• Prior authorization problems: A service required preapproval that was not obtained or was denied
• Out-of-network care: You received treatment from a non-network provider without emergency circumstances
• Documentation deficiencies: Provider failed to submit adequate records
• Benefit exclusions: The service is not covered under the MA state plan or MCO benefit package
• Eligibility gaps: Your enrollment lapsed during Pennsylvania's annual redetermination process

Managing Your Benefits Through COMPASS

Pennsylvania's COMPASS portal (compass.dhs.pa.gov) allows you to check your eligibility, update information, and manage your Medical Assistance benefits online. If you received a denial related to an eligibility determination, log into COMPASS or call the MA Customer Service Center at 1-800-692-7462 to review your case.

Step 1 — File a Grievance or Appeal With Your HealthChoices MCO

When your MCO denies a service or prior authorization, it must send you a written notice with:

• The specific reason for the denial
• The clinical criteria used
• Your right to appeal and the deadline

You have 45 days to file an internal MCO appeal. Submit it in writing and include supporting medical documentation. For urgent medical situations, request an expedited appeal — the MCO must respond within 72 hours.

Standard appeals must be resolved within 30 days. If your MCO upholds the denial, you can request a DHS fair hearing.

Step 2 — Request a DHS Bureau of Hearings and Appeals Fair Hearing

The Bureau of Hearings and Appeals (BHA) within DHS conducts fair hearings for Medical Assistance disputes. You have the right to a hearing if:

• Your MCO denied, reduced, or terminated a covered service
• Your eligibility was denied or terminated
• You disagree with a cost-sharing determination

To request a hearing, call the BHA at 1-800-799-7105 or mail a written request to the Bureau of Hearings and Appeals. You must file within 30 days of the MCO's final decision (or 30 days of the notice for eligibility disputes).

Continuation of benefits: If your benefits are being cut or terminated, file your hearing request within 10 days and ask for continuation of benefits. Your coverage continues at the prior level while the hearing is pending.

A BHA hearing officer conducts a formal proceeding. You can bring an attorney or advocate. The hearing officer issues a written decision. If you disagree, you can appeal to the Commonwealth Court of Pennsylvania.

Step 3 — External Complaint and Oversight

You can file complaints with DHS's Office of Medical Assistance Programs (OMAP) about MCO conduct. Pennsylvania also participates in external complaint processes through the Pennsylvania Insurance Department for some managed care disputes.

Special Situations in Pennsylvania

Community HealthChoices (CHC): This program serves people with physical disabilities and individuals 21+ who need long-term services and supports. If your personal care hours, home health, or other CHC services were reduced or denied, request a BHA fair hearing immediately. These services are critical for community living.

CHIP: Children's Health Insurance Program enrollees in Pennsylvania have the same appeal rights as MA enrollees. HealthChoices MCOs handle CHIP as well.

EPSDT: Children under 21 enrolled in Medical Assistance are entitled to EPSDT coverage for any medically necessary service. If a needed service was denied as "not covered," use EPSDT in your appeal.

Mental health and substance use services: Pennsylvania Medicaid covers behavioral health through county-based BH-MCOs. If your behavioral health service was denied, you may need to file a grievance with the BH-MCO rather than your physical health MCO.

Fight Back With ClaimBack

Pennsylvania's fair hearing process is thorough but requires well-organized documentation and timely action. ClaimBack helps you build a professional appeal letter that addresses the specific clinical and regulatory grounds for overturning your denial.

Start your Pennsylvania Medicaid appeal with ClaimBack

Related Reading

• Internal vs. External Insurance Appeal: Which Should You File?
• What Is Medical Necessity?
• How to Write an Insurance Appeal Letter