Part 4: Appendices: Glossary of Services, Acronyms, Sample Letters

Date

Division of Appeals and Hearings

Department of Health and Human Services

P.O. Box 8206

Columbia, SC  29202

Re: Request for Medicaid Fair Hearing

Dear Sir or Madam:

I am writing to request a Fair Hearing regarding the decision of [the Department of Health and Human Services, the  Office of Intellectual and Developmental Disabilities, OR specify a Managed Care Organization] to [deny eligibility, deny services, OR reduce services] through the [Medicaid program OR specify a Medicaid Waiver]. A copy of the denial is enclosed.

I feel this decision was incorrect for the following reasons: [List reasons why your denial is incorrect. Focus on showing why the person needs the service and supply any supporting documentation available from doctors and other medical professionals. You can also list any other alternatives that were tried and failed to meet the needs of the person.]

I have attempted to resolve this issue by: [List any correspondence with case managers or reviewers involved in making the decision.]

I would like: [Describe your ideal resolution, i.e., finding that the person is eligible for a waiver, approving services, etc.]

I request for my services to continue pending the outcome of the hearing. I also request a complete copy of my case file. Please let me know if you need anything further to proceed with this request.

Sincerely,

(Signature)

Print Name:

Address:

Telephone:

Email:

cc:

Disability Rights South Carolina

3710 Landmark Drive, Suite 208

Columbia, SC 29204