How to appeal a health coverage or benefits decision

If you don’t agree with a decision made by Health First Colorado (Colorado’s Medicaid program), you have a right to file an appeal.

Appeal means you disagree with a decision, and you ask in writing for a state fair hearing with a judge.

You generally have 60 days from the date on your Notice of Action, to ask for a state fair hearing. The Notice of Action is the letter that has the decision you disagree with.

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 get a response to your application.
• A service you get is set to be reduced or stopped. 
• You did not get notice at least 10 days before the date of action stating that
  • your health coverage was ending, or
  • covered services or benefits were set to be reduced or stopped.

Appeal an eligibility decision (whether you qualify for Medicaid)

If you disagree with a decision about whether you qualify for Health First Colorado (eligibility), you can

1. Ask for an informal meeting with your eligibility site or county.
2. File an appeal for a state fair hearing.
3. 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.

State fair hearing

You can ask for a state fair hearing with the Office of Administrative Courts no later than 60 days after the date of your Notice of Action if you

• disagree with a decision about your eligibility or benefits.
• filed an appeal with your health plan first and received a decision you did not agree with

State fair hearings are also known as “appeals” or “formal 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.

Appeal a benefits or services decision

If you disagree with a decision about your benefits or services, you may need to start the appeal process with the health plan or the company 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 or the company that manages those benefits and you disagree with their decision, you may ask for a state fair hearing.

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 on your letter. CHP+ eligibility appeals go to the Colorado Medical Assistance Program (CMAP).

For questions about the the CHP+ appeals process, contact CHP+ Customer Service at 800-359-1991 (State Relay: 711)

Rules: 10 CCR 2505-3 600

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How do I ask for a state fair hearing?

You must file your appeal asking for a state fair hearing no later than 60 days after the date in your Notice of Action.

If we reduced or stopped a service we previously authorized, you have the right to have your benefits continue until the appeal is resolved. Please go to the section titled “Continuing your benefits and services during an appeal.”

How to submit your appeal:

To ask the Office of Administrative Courts for a state fair hearing, please write, call, fax, or email:

Your letter must include:

• Your name and mailing address,
• Your signature (if mailing or faxing),
• Your daytime phone number
• Health First Colorado member ID, if applicable
• The decision that you are appealing. You may include a copy of the letter, which has the decision you disagree with.
• Reason you disagree with the decision

You can also complete, print the Office of Administrative Courts’ State level hearing request form.

Get help filing an appeal

Getting a faster appeal (expedited)

You can ask for a faster (expedited) appeal if you think waiting for a state fair hearing might put your life or health at risk. Let us know the health reason when you ask for a state fair hearing.

How to ask for a faster appeal

Follow the instructions for How to submit an appeal. Tell us that that you need a faster appeal and explain the health reason.

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

During the hearing you can explain why you believe you qualify for Health First Colorado, or why you should get the services your provider requested.

You can do this by providing evidence and information, testifying on your own behalf or asking other people or witnesses to testify to the court on your behalf.

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.

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Continuing your benefits and services during an appeal

Eligibility appeals

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 request for an appeal no later than 10 days after the date 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 we stopped or reduced a service we previously authorized, you have the right to have your benefits continue until the appeal is resolved.

To continue your services while you appeal, the Office of Administrative Courts must receive your request for an appeal no later than 10 days from the date of action.

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 your health plan stopped or reduced a service they previously authorized, you have the right to have your benefits continue until the appeal is resolved.

You must contact your health plan no later than 10 days from the date on the letter to request a continuation of benefits during your appeal.

If you lose the appeal to your health plan, you can file an appeal with the Office of Administrative Courts for a state fair hearing.

To continue your benefits during the appeal, the Office of Administrative Courts must receive your request no later than 10 days from the date 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 state fair 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 state fair 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

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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 state fair 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 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.

fee-for-service: When health care providers and organizations are paid for each service they provide to a patient.

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: Also called a “regional organization.” Health First Colorado partners with health plans to manage your benefits.

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.

Regional organization: You and your primary care provider belong to a regional organization (health plan) that helps you make sure you get the health care and services you need.

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.

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