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

Date

[Managed Care Organization Appeals Department Contact Information]

Re: Request for Reconsideration of [Denial or Reduction] of Medicaid Services

Dear Sir or Madam:

I am writing to request that [Managed Care Organization] reconsider its decision to [deny or reduce Medicaid services]. 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 person’s needs.]

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., approving the denied service.]

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.

Thank you very much for your assistance.

Sincerely,

(Signature)

Print Name:

Address:

Telephone:

Email:

cc:

Disability Rights South Carolina

3710 Landmark Drive, Suite 208

Columbia, SC 29204