When a Medicaid ride is denied: notices, appeals, and fair hearings
A denied Medicaid ride must come with a written notice giving the reason and the member's appeal rights. In fee-for-service programs, the member asks the state for a fair hearing, sometimes after a broker review, within up to 90 days (Virginia allows 30). Managed care members first appeal to their health plan within 60 days, and the plan must decide an urgent appeal within 72 hours.
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A denied ride is a decision, and every Medicaid decision comes with a right to challenge it. The member gets a notice, a deadline, and a path to someone other than the person who said no. Facility staff and case managers often know about the denial first, which makes them the people most able to keep the appeal on track. This guide covers the notice, the three appeal routes, the deadlines in three states, and what helps an appeal succeed.
Step 1: Work out who denied the ride
The appeal route depends on who made the decision. There are three common setups:
| Who runs the rides | Who issues the denial | Where the appeal goes |
|---|---|---|
| Fee-for-service Medicaid with a state broker | The broker, acting for the state | A state fair hearing, sometimes after a review by the broker |
| A managed care health plan | The plan or its transportation company | The plan’s appeal first, then a state fair hearing |
| A ride-only prepaid plan (a “NEMT PAHP” in federal rules) | The ride plan | Straight to a state fair hearing |
Federal fair hearing rules are in 42 CFR 431 subpart E. Managed care appeal rules are in 42 CFR 438 subpart F. Ride-only plans are exempt from the managed care appeal rules, and their members go to the state’s fair hearing instead, under 42 CFR 438.9. The denial notice should say who made the decision. If it does not, call the number on the notice and ask.
What the denial notice must say
A denial without a proper notice is a problem in itself. For fee-for-service decisions, 42 CFR 431.210 requires the notice to state:
- What action is being taken and when it takes effect
- The specific reasons for it
- The rules that support it
- The member’s right to a hearing and how to ask for one
- When Medicaid continues if a hearing is requested
When rides that were already approved are being stopped, reduced, or suspended, the notice generally must go out at least 10 days before the change (42 CFR 431.211).
A managed care plan’s notice, under 42 CFR 438.404, must also explain the right to free copies of the records behind the decision, including any medical necessity criteria used. It must explain how to ask for a faster appeal and how to keep benefits during the appeal.
State programs add their own timing. Georgia’s broker must mail or hand a written notice to the member within 3 business days of denying, suspending, or ending a trip, using letters the state approved. Missouri’s broker must give the member both verbal and written notice.
Common reasons rides are denied, and what to try
Some denials are fixed faster by rebooking than by appealing. Missouri’s April 2026 manual lists its denial reasons, and Virginia’s and Georgia’s rules share several of them. This table pairs the common ones with a first step.
| Denial reason | What to try first |
|---|---|
| Not enough notice | Ask whether the visit counts as urgent and have the medical office confirm it. Georgia treats follow-up care a provider wants in fewer than three days as good cause for short notice |
| Urgency not confirmed by the medical provider | Have the office call or fax the broker the same day |
| Appointment is for a service Medicaid does not cover | Check whether the service is covered. If it needed special approval, get that first; in Missouri, an approved exception request can open up rides |
| Provider is beyond the distance limit, or not the closest provider | In Missouri, show one of the exceptions: a history of non-routine care with that provider, a referral from the primary care physician, or no appointment within 30 days closer to home |
| Medical provider is not enrolled in Medicaid | Confirm enrollment with the office, or find an enrolled provider |
| Incomplete information | Rebook with the full details (see booking a Medicaid ride for a patient) |
| Member refused the assigned type of vehicle | Provide a clinician’s statement of why that mode does not work, such as a medical necessity form |
| Member has free transportation or other coverage | Explain why that option is not available for this trip |
| Child under 17 with no adult | In Missouri, arrange a parent, guardian, or another adult the parent designates |
| Over the daily trip limit | In Missouri, more than three legs a day needs approval from MO HealthNet |
| Member not eligible on the date of the ride | Check eligibility with the state; a pending application or a coverage gap may be the cause |
When rebooking will not work, appeal. The two can run side by side: a rebooked urgent ride for tomorrow does not waive the right to appeal the denial.
Denials over missed pickups
CMS’s 2023 coverage guide, SMD 23-006, says states may not deny rides because a member misses pickups or runs late, even often. States may add steps instead, such as a confirmation call the night before or the morning of the trip, or a single assigned transportation company. CMS also says a state should send the member a letter describing its efforts to accommodate them before limiting rides.
State manuals do not always read the same way. Georgia’s manual has its broker send a warning letter after two missed or late pickups, and deny service after two warnings, with appeal rights in the denial letter. A member facing that kind of denial can cite the CMS guidance. It also helps to ask for the trip records behind each missed pickup, because a late driver can look like a no-show on paper.
Deadlines by route
Deadlines are strict. A missed deadline can end the appeal before anyone looks at the facts.
| Route | Time to file | Time to decide |
|---|---|---|
| Fee-for-service, federal floor | The state sets a reasonable time, up to 90 days from the date the notice was mailed | Usually within 90 days of the hearing request |
| Missouri fee-for-service | 90 days from the written denial to request a state fair hearing; the broker is a party | State fair hearing before an impartial hearing officer |
| Virginia fee-for-service (MTM Health, trips on or after October 1, 2026) | 30 days from the written denial, filed with the DMAS Appeals Division | The Appeals Division contacts the member |
| Georgia | 30 calendar days to appeal to the broker; if the broker still denies, the member can appeal to the DCH Client Appeals Unit | 30 calendar days for the broker’s review |
| Managed care plan, federal floor | 60 calendar days from the notice to appeal to the plan | 30 calendar days, extendable by 14; 72 hours for an expedited appeal |
| After a managed care appeal | 90 to 120 days from the plan’s decision (the state sets the exact number) to request a state fair hearing | Usually within 90 days of the date the plan appeal was filed, not counting the days the member took to request the hearing |
Virginia’s Appeals Division takes appeals through its online portal, by email to appeals@dmas.virginia.gov, by fax to (804) 452-5454, by phone at (804) 371-8488, or by mail or in person at 600 E. Broad Street, Richmond, VA 23219.
In managed care, the member usually must finish the plan’s single level of appeal before asking for a fair hearing. The exception protects members from delay: if the plan misses its notice or timing rules, federal rules treat the plan appeal as finished, and the member can go straight to a hearing. A plan appeal can be made by phone or in writing, and plans must treat a phone call asking to appeal as an appeal.
Urgent trips: ask for a fast appeal
A standard appeal can take a month, which is useless for a ride needed this week. Both routes have a faster track.
- Managed care. Under 42 CFR 438.410, a plan must expedite an appeal when the member’s provider indicates that waiting could seriously jeopardize the member’s life, health, or ability to regain maximum function. The plan then has 72 hours. A plan may not take punitive action against a provider who asks for an expedited appeal or supports a member’s appeal.
- Fair hearings. Under 42 CFR 431.224, states must run an expedited fair hearing process when the standard timeline could jeopardize the member’s life, health, or function. The state must tell the member quickly whether the request was granted.
If a plan or hearing officer reverses a denial of a ride that did not happen, the plan must authorize or provide it as fast as the member’s health requires, and no later than 72 hours after it receives notice of the reversal (42 CFR 438.424).
For a visit that cannot wait even 72 hours, ask the broker again whether it qualifies as urgent while the appeal goes forward. Every program in this guide books urgent trips with less notice.
Keeping rides going during an appeal
For rides that were already approved and are being cut or stopped, federal rules let the member keep them during the appeal if they act quickly.
- Fee-for-service. If the member requests a hearing before the change takes effect, the state generally may not stop or reduce the service until the hearing decision (42 CFR 431.230). In most cases, a state must also reinstate services when the member asks within 10 days of receiving a notice that arrived without the required advance warning.
- Managed care. The plan must continue benefits when the member files the appeal on time, the rides were authorized by a provider, the authorization has not run out, and the member asks for continuation within 10 days of the notice or by the date the change takes effect, whichever is later (42 CFR 438.420).
There is a cost risk. If the member loses, the state or plan may recover the cost of rides provided only because of the appeal. Georgia’s broker keeps transporting members during its appeal process, except where documented unsafe or abusive behavior continues.
For standing orders such as dialysis rides, ask for continuation in the same call or letter as the appeal.
How facilities and case managers can help
Staff cannot win an appeal for a member, but they can supply most of what wins one.
- Mark the deadline the day the notice arrives. Count from the date on the notice. For fee-for-service continuation, federal rules treat a notice as received 5 days after its date unless the member shows otherwise.
- Get consent to act. For a fair hearing, the member can be represented by a relative, friend, lawyer, or other spokesperson (42 CFR 431.206). In managed care, a provider or authorized representative can file with the member’s written consent where state law allows it.
- Ask for the file. Managed care members get their case file free, including the criteria used (42 CFR 438.406). Plans must also help with forms and provide interpreters and TTY access.
- Supply the medical side. A short letter from the treating clinician on why the visit is needed, why this provider, and why this type of vehicle answers most denial reasons. For distance denials, include proof of the exception the state recognizes.
- Document the trip history when the denial rests on missed pickups: dates, scheduled times, and when the driver arrived, if known.
- Keep copies of everything sent and write down every call: date, time, name, and reference number.
If the problem is how a ride went rather than a decision about it, that is a complaint, not an appeal. See filing a complaint about Medicaid transportation. For what Medicaid rides cover in the first place, see what Medicaid transportation covers.
Trip records that settle disputes
Appeals over missed pickups turn on what really happened at the curb. Transportation companies that run on HealthRide keep GPS miles, timestamps, signatures, and recorded wait times on no-shows for every trip, and can export the trip log as a CSV or PDF. That record shows whether the driver arrived on time and how long the driver waited. See reports.
Frequently asked questions
- Once a ride is denied, how long does the member have to appeal?
- It depends on who denied it. Federal rules let a state allow up to 90 days from the notice to request a fair hearing, and Missouri allows the full 90. Virginia's fee-for-service members have 30 days from the written denial, and Georgia members have 30 calendar days to appeal to the broker. Managed care members have 60 days from the notice to appeal to their plan, then 90 to 120 days after the plan's decision to request a fair hearing.
- Can the doctor's office or case manager file the appeal?
- Often, yes. In a fair hearing, the member can be represented by a relative, friend, lawyer, or other spokesperson. In managed care, a provider or authorized representative can file the appeal with the member's written consent where state law allows it. A provider cannot ask a plan to continue services during the appeal, so the member or their representative should make that request.
- Will the member keep getting rides during the appeal?
- Sometimes. When rides that were already approved are being cut or stopped, asking for a hearing or appeal within 10 days of the notice usually keeps them going until the decision. The member may have to repay the cost if they lose. Georgia's broker keeps providing rides during its appeal process, except where documented unsafe behavior continues.
- Is a complaint the same as an appeal?
- No. An appeal challenges a decision, such as a denied, reduced, or stopped ride. A complaint, called a grievance in managed care, covers everything else: a late driver, a dirty van, rude staff. Missouri sends denials to a state fair hearing and handles complaints through the broker. The two are separate filings, so a complaint never replaces an appeal.
- What if the health plan never answers the appeal?
- The member can go straight to a state fair hearing. Federal rules treat a plan that misses its notice or timing requirements as if its appeal process were finished, which lets the member request a hearing without waiting any longer.
- Can rides be denied because the member missed pickups?
- CMS says states may not deny rides over no-shows or lateness, even repeated ones, though they can add steps such as confirmation calls. Georgia's manual lets its broker deny service after two warning letters about missed or late pickups, and the denial letter must explain how to appeal. A member facing that kind of denial can cite the CMS guidance and ask what the records show about each missed trip.
