Medicaid managed care claim disputes: the state reviews that come after a plan's final denial

The federal rules stop at the member’s appeal

Federal managed care rules build an appeal system for members, not for providers’ claims. A provider can file a member’s appeal only with the member’s written consent (42 CFR 438.402), and the part of those rules aimed at providers requires the plan to explain that member system to every provider and subcontractor when they sign (42 CFR 438.414). Your right to fight a short payment comes from your contract and from state law.

The same rules leave the plan answerable for any work it hands to a subcontractor, including a transportation broker. Under 42 CFR 438.230, the plan keeps ultimate responsibility for meeting its state contract whatever its subcontracting arrangements. Louisiana’s bulletin follows that chain: an unresolved broker problem goes to the plan, then to the state.

The first levels of an appeal, from reconsideration to a formal appeal, are covered in appealing a denied NEMT claim. This page starts where those end.

Start with whoever decided the claim

The review you can get depends on who issued the decision, so read the remittance before anything else. A plan that paid the claim itself is subject to the state programs below. A broker that paid the trip runs its own reconsideration and appeal under your service agreement.

Louisiana spells out the order for transportation providers. Its bulletin for them, IB 21-02 in the September 8, 2026 revision, puts the broker first, ahead of the plan, any third party, or LDH, and it lists MediTrans as the claims contact for every Healthy Louisiana plan. UnitedHealthcare’s contract with LDH ended April 1, 2026, and its claims for earlier dates of service must be submitted by March 31, 2027. First comes a reconsideration request, which has to reach the broker by day 180 after the remittance paid date or the original denial. Then comes an appeal, due 90 days after the broker’s answer (Louisiana Healthcare Connections allows 180). The broker decides each one within 30 days. After that, the bulletin lists a formal complaint to the plan, then LDH’s transportation staff, with independent review as another option. The MediTrans guide has the contacts.

Most state routes open only after the plan’s own process ends. Kentucky’s review requires an exhausted internal appeal, Georgia’s starts once the plan’s internal appeals are done, and Texas wants the plan’s complaint process tried first. Florida lets plan contracts signed or renewed since October 1, 2000 require it.

The state routes side by side

Four states give providers an outside decision-maker once a plan says no, and Texas takes complaints at the state agency. The windows are short.

Florida: the statewide claim dispute program

Florida’s program under section 408.7057 sends unresolved disputes to an independent resolution organization under contract with AHCA, currently Capitol Bridge. It takes disputes over payment amounts only: denials in full or in part, underpayments, and overpayment demands. Disputes about interest or late payment alone are not eligible, and neither are claims that are the basis of a pending lawsuit or part of a Medicaid fair hearing.

• No minimum for most providers. Hospitals and physicians must add up claims to reach set thresholds. AHCA’s list sets no threshold for other providers.
• Medicaid plans must take part. Since 2018, AHCA’s Statewide Medicaid Managed Care contract has required every plan to participate.
• Documents within 15 days. Once the resolution organization asks, the filing side has 15 days to send its documentation or the dispute is dismissed. A respondent that misses its own 15 days is defaulted, with a recommendation that it pay the full disputed amount plus accrued interest.
• A recommendation within 90 days. The organization recommends a resolution within 60 days of receiving the requested information, and never more than 90 days after the dispute was filed. AHCA adopts it as a final order within 30 days.
• The loser pays. The side that does not prevail pays the review cost. Unpaid after 35 days, it faces a penalty of up to $500 a day.
• Refusing a fair offer costs money. A provider’s offer to settle an underpayment must exceed 110 percent of what it was paid. If the other side refuses and the final order lands between 90 and 110 percent of the offer, the side that refused pays the order amount and counts as the losing party.

AHCA’s report counts 162 disputes filed in 2025, of which 125 were accepted for review. The statute lets providers file against health plans as it defines them: HMOs, prepaid health clinics, prepaid health plans, exclusive provider organizations, and insurers. A transportation broker is not on that list, so ask the resolution organization (FLCDR@capitolbridge.com) before filing over a trip a broker paid. The Florida NEMT guide covers who pays rides there.

Louisiana: independent review in two steps

R.S. 46:460.81 gives a provider the right to independent review of any adverse claim decision a Medicaid plan sends by remittance or notice. A contract term that limits the process is void, and for claims filed on or after January 1, 2018, the state may not force the dispute into arbitration. The process runs as follows:

1. Ask the plan to reconsider. Send a written request naming the claims, the reasons, and your documents within 180 days. The 180 days run from the remittance date (its transmission or postmark), from the recoupment, or, when the plan sent nothing, from the 60th day after you submitted the claim. The plan must acknowledge it within 5 calendar days and decide within 45.
2. Go to LDH. If the plan upholds its decision or misses its deadline, LDH must receive your request within 60 days, with a copy of the reconsideration request. LDH refers it to an independent reviewer.
3. Send the record. Within 14 days, the reviewer asks both sides for their documents, which are due within 30 days. The reviewer will not look at anything you did not give the plan with the reconsideration request.
4. Get the decision. The reviewer decides within 60 days of receiving the record. A plan that loses pays the claim in full, with interest back to the date of denial or recoupment, within 20 days.

The plan pays the reviewer’s fee, which LDH lists as $750. A provider who loses must repay that fee within 10 days, or the plan can withhold it from later payments and must show the withholding on the remittance. With LDH’s approval, a provider can combine claims against one plan that turn on a common question of fact or law. Either side has 60 days after the decision to sue, and the court hears the dispute fresh. The statute excludes decisions already in litigation or arbitration and those not tied to a Medicaid enrollee, and LDH treats special investigation unit post-payment findings as outside the process.

Kentucky: an outside review, then a hearing

Under KRS 205.646, a provider who has finished a Medicaid plan’s written internal appeal is entitled to an external independent third-party review of a final decision denying a claim. The plan’s final letter has to say that internal appeals are exhausted, that the review is available, and where and by when to ask. The regulation, 907 KAR 17:035, sets the steps:

• Ask within 60 calendar days. The request goes to the plan electronically, by fax, or by mail. The count starts on the day an electronic or faxed decision arrives, or on the postmark date of a mailed one, with 3 days added for mail.
• Stick to the record. The request names each issue and why the plan was wrong, limited to what you sent in the internal appeal and what the plan’s decision contains.
• Who decides. Medical necessity disputes go to licensed clinicians, and disputes over coverage or plan requirements go to the Department for Medicaid Services. The reviewer decides within 30 days of receiving the record.
• Then a hearing. The losing side can ask for an administrative hearing within 30 calendar days of the department’s notice. The hearing fee can reach $1,000 and is paid by the side that loses. A plan that loses must pay within 60 days after appeal rights run out.

The statute also allows several claims in one review when the provider alleges that a plan policy or practice caused the denials. It covers providers licensed in Kentucky as defined in KRS 304.17A-700, which points to a list in KRS 304.17A-005: physicians, dentists, pharmacists, facilities licensed under KRS Chapter 216B, and similar licensed professions. Transportation companies are not named, so confirm that your license type qualifies before you count on this route. The program design narrows it further. Kentucky runs its Medicaid NEMT program through regional brokers paid by capitation, and 2026 Ky. Acts ch. 179, section 14, keeps that program separate from transportation, including stretcher trips, that a plan covers. KRS 205.646 reaches only the trips a plan itself pays for. The Kentucky NEMT guide explains the regional brokers.

Georgia: an administrative hearing or binding arbitration

Georgia’s care management organization law, O.C.G.A. 33-21A-7, makes plans let providers bundle appeals that raise the same payment or coverage issue, whatever the number of members or claims. Once the plan’s internal appeals are exhausted, the provider chooses one of two routes:

• Administrative hearing. Under O.C.G.A. 49-4-153(e), the written request goes to the Department of Community Health no later than 15 business days after you receive the plan’s decision. The Office of State Administrative Hearings assigns a judge within 15 days, the hearing starts within 90 days of assignment, and the decision follows within 30 days after the record closes. The judge can consolidate similar claims against one plan, and the judge’s decision is the final administrative remedy.
• Binding arbitration. A private arbitrator certified by a national alternative dispute resolution association hears the case, under American Arbitration Association rules if the parties cannot agree. The ruling comes within 90 days of selection and binds both sides, and costs other than attorney fees are split equally.

A claim first denied or underpaid and later found owed carries interest of 20 percent a year, counted from 15 days after it was submitted. The law defines a provider as one under contract with a plan. Georgia’s NEMT program serves eligible Medicaid members through brokers under contract with DCH, with Verida in all five regions since April 1, 2026, so most ride disputes there run under the broker’s service agreement rather than this law. Appealing a denied NEMT claim covers those broker terms.

Texas: a complaint, not a review

Texas gives managed care providers a complaint route rather than an outside reviewer. Work through the plan’s own complaint or appeal process first. If that fails, send the complaint to HHSC at hpm_complaints@hhs.texas.gov or through the state’s online complaint form, with your name, NPI, phone number, and contact person, plus the member’s Medicaid ID. Complaints that are not about a health plan go to TMHP’s Complaints Resolution Department at 800-925-9126 or P.O. Box 204270, Austin, TX 78720-4270. CHIP plan complaints go to the Texas Department of Insurance at ConsumerProtection@tdi.texas.gov.

Build the packet once, at the first level

Louisiana’s reviewer ignores documents the plan never saw at reconsideration, and Kentucky’s review is limited to what you sent in the internal appeal. In practice, the outside review is decided on the packet you built at the first level, so make it complete then:

1. The claim identifiers: your NPI, the payer’s claim number, the trip ID or authorization number, the ride date, and the rider’s Medicaid ID.
2. The decision you dispute, with the remittance or letter that carries it.
3. The state rule or contract clause the decision breaks, quoted word for word.
4. The trip record: the rider’s signature, the miles driven, and the clock times for pickup and drop-off, as described in NEMT documentation requirements.
5. Every earlier request, with its date and any reference number the plan or broker gave you.
6. The exact amount you are asking for, claim by claim.

Calendar each deadline the day the decision arrives. A missed 15-business-day window in Georgia, or a 60-day window in Kentucky, ends the route no matter how strong the claim is.

Proof that holds up at the last level

A reviewer months later sees only what was recorded when the ride happened. HealthRide stores the scheduled and actual times for every trip leg, along with the rider’s on-screen signature, any recorded no-show wait, and the GPS-recorded miles. Its trip log exports those records as a PDF or spreadsheet, so the evidence behind the first request and the last one is the same file.