Appeals (if you disagree with a health coverage decision)
You have a right to file an appeal. You can appeal if you disagree about a decision about whether you qualify for Health First Colorado (Colorado’s Medicaid program). You can also appeal any decision about services that you receive.
Appeal means you disagree with a decision, and you ask in writing for a formal hearing (state fair hearing) with a judge.
You must appeal within 60 days of the date on the letter that has the decision you disagree with. This letter is also called a Notice of Action.
What can I appeal?
Things you can appeal include:
- You no longer qualify for Health First Colorado (Colorado’s Medicaid program).
- Your application for Health First Colorado was denied.
- You didn’t receive a response to your application.
- A service you get is set to be reduced or stopped.
- You did not get notice that
- your health coverage was ending, or
- covered services or benefits were set to be reduced or stopped.
Benefits and services appeals
If you disagree with a decision about your benefits or services, you may need to start the appeal process with the health plan that manages those benefits.
Follow the directions in your letter, and pay attention to the deadlines. If you miss a deadline you may lose or have a gap in your coverage.
If you file a benefits or services appeal with your health plan and you disagree with their decision, you may ask for a formal hearing.
Eligibility appeals (whether you qualify for Medicaid)
If you disagree with a decision about whether you qualify for Health First Colorado (eligibility), you can
- Ask for an informal meeting with your eligibility site or county.
- File an appeal for a formal hearing (state fair hearing).
- Ask for both an informal meeting and file an appeal at the same time.
Informal meeting
If you disagree with an eligibility decision, you can ask for an informal meeting with your county or eligibility site.
Ask for an informal meeting within 60 days of the date in your Notice of Action.
Asking for an informal meeting does not guarantee you can keep your coverage after the termination date listed on the letter.
To continue your health coverage past your termination date, you must ask for a formal hearing (state fair hearing).
Formal hearing (state fair hearing)
You can ask for a formal hearing with the Office of Administrative Courts within 60 days of the date of your Notice of Action if
- You disagree with a decision about your eligibility or benefits.
- You already followed the appeals process with your health plan and disagreed with their decision.
Formal hearings are also known as “appeals” or “state fair hearings.”
Appeals are decided by an administrative law judge from the Office of Administrative Courts. They will listen to both sides before making a decision.
Good to know:
- Asking for a formal hearing is the only way to keep your health coverage during the appeals process.
- Pay attention to the date: If you try to appeal after 60 days, the Office of Administrative Courts may not accept your appeal.
Child Health Plan Plus (CHP+) appeals
If you do not qualify for CHP+ when you renew, or if you disagree with a decision about your services, follow the appeals process in your letter.
Questions?
Contact CHP+ Customer Service at 800-359-1991 (State Relay: 711)
How do I ask for a formal hearing (state fair hearing)?
You must file your appeal asking for a formal hearing within 60 days of the date in your Notice of Action.
To start your appeal, follow the directions in the Notice of Action or Notice of Adverse Benefit Determination.
You can file a formal appeal in any of these ways:
- Fill out the Request for State Level Hearing Form.
Find this form on the Office of Administrative Courts forms page under General Services Forms.
- Write a letter to the Office of Administrative Courts.
Your letter must include:
-
- Your name,
- Your signature (if mailing or faxing),
- Your mailing address, and
- Your phone number.
Helpful to include, but not required:
-
- A case number or Member ID.
- Reason you disagree with the decision.
- A copy of the decision letter.
- A request for an interpreter or other accommodations (if needed).
Mail, fax, email or bring your Request for State Level Hearing Form OR letter to:
Mail and in-person:
Office of Administrative Courts
1525 Sherman St., 4th floor
Denver, CO 80203
Fax: 303-866-5909 (10 pages or fewer; otherwise, mail your request)
Email: oac-gs@state.co.us.
- Request an appeal online using the Office of Administrative Courts e-filing system. You must create an account to file online.
Getting a faster appeal (expedited)
You can ask for a faster (expedited) appeal if you think waiting for a formal hearing might put your life or health at risk.
Let us know that you want an expedited hearing in the Request for State Level Hearing Form and explain the health reason.
Find this form on the Office of Administrative Courts forms page under General Services Forms.
What happens after I file an appeal?
The Office of Administrative Courts sets a hearing date
After the Office of Administrative Courts gets your request, they will mail you the date, time, and place for your hearing.
Prepare for the hearing
You can represent yourself or ask someone to represent you. That person can be a provider, an advocate, a lawyer, a family member or any other person you trust.
If you want someone who is not a lawyer to represent you, fill out the Non-Attorney Authorization Form. Both of you must sign the form.
Return the form to the Office of Administrative Courts.
Attend the hearing
This is where you get to share your story and explain why you believe you qualify for Health First Colorado, or why you should get the services your provider requested.
Initial decision
In most cases the judge will make a written decision in 20 days. The Office of Appeals will send you a copy of the judge’s decision, called a Notice of Initial Decision.
If you disagree with the judge’s initial decision, you can file a written exception to the Office of Appeals within 18 days of getting the Notice of Initial Decision.
Exceptions are your written arguments stating why you believe the initial decision is incorrect.
Final agency decision
After reviewing the judge’s initial decision, any written exceptions and any responses from the other side, the Office of Appeals will send their Final Agency Decision.
Keeping your coverage during an appeal
Eligibility appeals
If you get a Notice of Action saying you no longer qualify for Health First Colorado, you can ask for a formal hearing (a state fair hearing).
To keep your coverage during the eligibility appeals process
- You must be a current Health First Colorado member.
and
- The Office of Administrative Courts must get your written request for appeal (state fair hearing) within 60 days of the Notice of Action.
Your coverage will continue until a final decision is made on your appeal.
Note: If you are applying for Health First Colorado for the first time and you do not qualify, you can appeal. However, there is no continuation of benefits.
Benefits appeals
If you get a notice denying or reducing your benefits or services, you can ask for a formal hearing (a state fair hearing).
To keep getting the benefit or service you are receiving,
- The Office of Administrative Courts must get your written request for appeal (state fair hearing) within 60 days of the notice of denial or reduction of benefits.
Your benefits or services will continue until a final decision is made on your appeal.
Note: If you ask for a new benefit or service, and you get denied, there is no continuation of benefits or services.
Health plan appeals
If you get a letter (Notice of Adverse Benefit Determination) from your health plan telling you they are ending or changing your services, and you disagree with this decision, you can appeal to your health plan.
If you file an appeal with your health plan within 60 days of the date on the notice, you can continue your benefits during your appeal.
If you lose the appeal to your health plan, you can ask for a formal hearing (state fair hearing).
To continue your benefits, The Office of Administrative Courts must get your written request for appeal (state fair hearing) within 120 days of the health plan’s final decision.
How to file an appeal for a formal hearing
Getting help with an appeal
Contact these government offices with questions:
Health First Colorado Member Contact Center
The Health First Colorado Member Contact Center is who you should contact if you have questions about Medicaid.
Phone: 800-221-3943 (State Relay: 711)
Office of Administrative Court’s Clerk’s Office
The Office of Administrative Court’s Clerk’s Office may be able to help you with questions about how to file an appeal, questions about your hearing, and any questions about how to get information to your judge.
Phone: 303-866-5626
Help with benefits appeals:
Contact the health plan that manages your benefits for help. The contact information will be listed in your letter.
Health First Colorado Managed Care Ombudsman
Phone: 877-435-7123 or TTY 888-876-8864 or State Relay: 711.
Email: help123@maximus.com
If you’re appealing a decision made by Health First Colorado, then an Appeals Navigator will contact you.
Legal help
These organizations may be able to help you with legal questions:
Colorado Legal Services (CLS)
CLS may be able to help. They provide legal help for low-income Coloradans with civil legal needs, and they are free.
Call CLS at 303-837-1313, or fill out their online intake form at: coloradolegalservices.org
Colorado Cross-Disability Coalition (CCDC)
CCDC has non-lawyer advocates who may be able to help with appeals if you have a disability.
Call the main office at 303-839-1775. Learn more at ccdconline.org/contact.
Remember: You don’t have to have a lawyer. You can ask for an appeal by yourself, or with someone who is not a lawyer. If you have a case manager, you can ask them for help.
Accommodations or interpreters
You have the right to ask for accommodations or an interpreter during your hearing.
Auxiliary aids and services for individuals with disabilities and language services for individuals whose first language is not English may be provided upon request. Requests should be made as soon as possible. Contact information for each hearing type is listed below.
For accommodations for formal hearings, contact:
Office of Administrative Courts
1525 Sherman St., 4th floor
Denver, CO 80203
Phone: 303-866-5626 (State Relay: 711)
Tell them:
- Your name
- Your case number
- The date of your formal hearing
- The specific accommodations or language interpretation that you need for your formal hearing
For accommodations for approved expedited hearings, contact:
Colorado Department of Health Care Policy and Financing Office of Appeals
303 E. 17th Avenue
Denver, CO 80203
Phone: 303-866-5654
Fax: 303-866-4411
Email: hcpf_officeofappeals@state.co.us
Tell them:
- Your name
- Your contact information
- Your case number
- The date of your expedited hearing
- The specific accommodations or language interpretation that you need for your expedited hearing
Glossary (definitions) of appeals terms
appeal: A written request sent to a state office saying you disagree with an eligibility or benefits decision, and you want a formal hearing with an administrative law judge.
appeals navigator: The person who helps you with benefits appeals decisions made by the Colorado Department of Health Care Policy and Financing or Acentra.
appellant: The person who disagrees with an eligibility or benefits decision, and requests a hearing with an administrative law judge.
appellee: The organization that sends the Denial or Reduction Notice of Action, application denial or termination notice.
approved expedited hearing: A request for a faster appeal that’s been approved by the Colorado Department of Health Care Policy and Financing Office of Appeals.
benefits: Health care services, medicine and supplies that are covered by Health First Colorado.
date of action: means the intended date on which a termination, suspension, reduction, transfer or discharge becomes effective.
eligibility: Whether or not someone qualifies for a program like Health First Colorado.
exceptions: Written arguments stating why you believe the administrative law judge’s initial decision is incorrect.
expedited hearing: A faster formal (eligibility) appeal, requested if waiting for an appeal will endanger the Appellant’s health.
extensions: Requests for more time to do something, like review the judge’s initial decision or order a transcript.
Final Agency Decision: A letter issued by the Colorado Department of Health Care Policy and Financing Office of Appeals after they review the judge’s initial decision, any written exceptions, and any responses from the other side.
formal hearing: A meeting with an administrative law judge from the Office of Administrative Courts. Also known as “state fair hearing” or “appeal.”
HCPF: Acronym for the Colorado Department of Health Care Policy and Financing, the agency that administers Health First Colorado (Colorado’s Medicaid program) and Child Health Plan Plus (CHP)+.
health plan: The organization or company that Health First Colorado works with to manage your benefits, like Elevate Medicaid Choice (formerly known as Denver Health) and Rocky Mountain Health Plan Prime.
informal meeting: A discussion with your eligibility site about their decision on your coverage (eligibility).
Notice of Action: A letter sent to people who apply for Health First Colorado, or are already enrolled, regarding a denial, approval, termination and/or changes to their eligibility or benefits.
Notice of Initial Decision: The administrative law judge’s decision on your appeal. This is not a final decision.
Office of Administrative Courts (OAC): Colorado’s centralized administrative court system. This administrative court system lets agencies and citizens resolve certain disputes while avoiding the time and expense of going to district court.
Office of Appeals: The team of legal experts at the Colorado Department of Health Care Policy and Financing who review all sides of an appeal case and issue a Final Agency Decision.
Ombudsman: People who help settle grievances, appeals and other issues related to your health care.
quick appeal: A faster benefits appeal, requested with the managed care organization (Denver (Elevate) Health Medicaid Choice or Rocky Mountain Health Plan Prime) if waiting for a benefits appeal will endanger the Appellant’s health.
regular appeal: A meeting with an administrative law judge from the Office of Administrative Courts. Also known as “formal hearing” or “state fair hearing.”
State Fair Hearing: A meeting with an administrative law judge from the Office of Administrative Courts. Also known as “formal hearing” or “appeal.”
written exception: Exceptions are your written arguments stating why you believe the Initial Decision is incorrect, based on either incorrect factual findings or improper conclusions of law.
