Appeal a DHS Decision

Who can appeal?

Anyone has the right to appeal any decision made by the Department of Human Services and to request an appeal hearing.  No one may limit or interfere with this right.

How do I file an appeal?

Filing an appeal is an easy thing to do.  Food Assistance, Medicaid, Child Care Assistance, Family Planning Program, and Family Investment Program appeals may be made in person, by telephone or in writing.  All other appeals must be requested in writing.

You can write a letter explaining the reason you disagree with the Department's decision or you can complete an Appeal and Request for Hearing form online at Appeal and Request for Hearing English version or Appeal and Request for Hearing Spanish version

Appeal and Request for Hearing form

You can request this form from your worker or you can complete your request online.  You can use the Appeal and Request for Hearing English version or the Appeal and Request for Hearing Spanish version.  Please fill out the entire form and click the submit button at the bottom of the form.  Your appeal request will be sent directly to the Appeals Section.  Your worker will be notified of your appeal request, if applicable.

If you have questions on how to complete the Appeal and Request for Hearing form, you may call the Appeals Section at (515) 281-3094.

If you are writing a letter or you do not want to complete this form on-line, you can send or take your appeal request to your local office or you can submit it directly to the Appeals Section at:

      Department of Human Services
      Appeals Section
      1305 E Walnut Street, 5th Floor
      Des Moines, IA  50319
      Phone 515-281-3094
      FAX 515-564-4044
      Email:  appeals@dhs.state.ia.us  


When a managed care network provider or authorized representative disagrees with an action taken by the managed care organization, the provider or authorized representative may file an appeal on behalf of a Medicaid member, if the member has given their express written consent.   

Member consent must be obtained on form 470-5526, Authorized Representative for Managed Care Appeals.  This form is used to appoint an individual, organization or provider to act on behalf of the Medicaid member during the appeals process.  The form will be used for the managed care organization (MCO) and dental carriers’ first level appeals process and for the Department’s state fair hearing process.

 
This form should be completed by the Medicaid member or their parent or guardian, if applicable. The member and the authorized representative must both sign the form. Once completed, the form must be submitted to the Medicaid member’s MCO, dental carrier or to the DHS Appeals Section, along with an appeal request.  
 
The form shall be submitted to your managed care organization for a first level review at:
 
Amerigroup Iowa Inc 
Grievances and Appeals Department 
4800 Westown Pkwy Ste 200 
West Des Moines, IA  50266 
Email:  iga@amerigroup.com
 
United Healthcare Community Plan
Grievance and Appeals
200 PO Box 31364
Salt Lake City, UT  84131-0364
 
Delta Dental of Iowa
Attn:  DWP Appeals and Complaints
PO Box 9040
Johnston, IA  50131-9040
 
MCNA Dental
Attention:  Grievance and Appeals Department
200 West Cypress Creek Rd Ste 500
Fort Lauderdale, FL  33309
 
Immanuel Pathways
PACE Program – Southwest Iowa
1702 N 16th St
Council Bluffs, IA  51501
 
Immanuel Pathways
PACE Program – Central Iowa
7700 Hickman Rd
Windsor Heights, IA  50324
 
Siouxland PACE
1200 Tri View Ave
Sioux City, IA  51103

 

The form shall be submitted to you’re the DHS Appeals Section for a state fair hearing at:
 
Department of Human Services
Appeals Section, 5th Fl
1305 E Walnut St
Des Moines, IA  50319-0114
FAX:  515-564-4044
Email:  appeals@dhs.state.ia.us
 

Federal regulations and the managed care contract do not allow providers to file appeals with our office regarding claims payment disputes or post-service provider issues.   

Is there a time limit on when I can file an appeal? 

You must file an appeal within the timeframes listed.  The time starts from the date on your Notice of Decision.

  • Family Investment Program (FIP) state tax or debtor offset - 15 days
  • Food Assistance state tax or debtor offset - 15 days
  • Medicaid state tax or debtor offset - 15 days
  • Child Support state or federal tax or debtor offset - 15 days
  • Food Assistance - 90 days
  • Medicaid eligibility – 90 days
  • Medicaid fee-for-service coverage – 90 days
  • Family planning program – 90 days
  • Autism support program – 90 days
  • Managed care organization health care decisions – 120 days from the date on the letter indicating the first-level review process has been exhausted
  • Child abuse assessments - 90 days from the date on the Notice of Child Abuse Assessment
  • Adult abuse assessments – 6 months from the date on the Adult Protective Notification
  • All other appealable issues - 30 days or before the effective date of the adverse action

When the time limit for filing falls on a holiday or a weekend, the time will be extended to the next working day.

If you file your appeal within the appropriate timeframe and the Department determines you are eligible for a hearing, a hearing will be scheduled for you.
 

However, if any appeal is filed after the appropriate timeframe, but before 90 days, a hearing may still be granted if you are able to claim good cause.  You do not have to show good cause for filing a Food Assistance, Medicaid eligibility, Medicaid fee-for-service, family planning program, or autism support program or child abuse appeal within the 90-day timeframe.

 
Any appeals filed after 90 days will not be granted a hearing, unless the appeal is related to adult abuse or a managed care organization decision.  Any appeals filed after 6 months for adult abuse will not be granted a hearing.  Any appeals filed after 120 days for a managed care organization health care decision will not be granted a hearing. 
 

How do I claim good cause for not filing an appeal timely?

If your appeal is not filed within the timeframes listed above, but less than 90 days, a hearing may still be granted.

If you want to claim good cause, you will need to write a letter to the following address explaining why you were unable to file your appeal within the appropriate timeframes. 

    Department of Human Services
    Appeals Section
    1305 E Walnut St, 5th Floor
    Des Moines, IA  50319
    Phone (515) 281-3094
    FAX (515) 564-4044
    Email:  appeals@dhs.state.ia.us  


A hearing may be granted if one of the following reasons kept you from filing your appeal within the appropriate timeframes:

1.    A serious illness or death in your family.

2.    A family emergency or household disaster, such as a fire, flood or tornado.

3.    A failure to receive the Department's notice of adverse action for a reason beyond your control.  (Failure to notify the Department you moved will not be considered.)

4.    Other good cause beyond your control.

You will need to include written proof of your good cause claim.  Written proof includes such things as funeral notices, letters from physicians, newspaper articles, etc. that explain why you could not file your appeal timely.

If it is determined that you had good cause, your appeal will be scheduled for a hearing.  If it is determined that you do not have good cause, a letter will be sent to you indicating that if you disagree you may appeal that letter.  If you appeal that letter, a hearing will be scheduled with an Administrative Law Judge to determine if the Department correctly denied your good cause claim.  The hearing will not be about the merits of your case. 

Can providers or authorized representatives file an appeal on behalf of a Medicaid member? 

Federal regulations allow providers and authorized representatives to file an appeal on behalf of a Medicaid member for managed care appeals when the member has given their express written consent.

Form 470-5526 shall be used to appoint an individual, organization or provider to act on behalf of the Medicaid member during the appeals process.

Both DHS and the Managed Care Organizations (MCOs) utilize form 470-5526, Authorized Representative for Managed Care Appeals, to obtain the member's consent.

Form 470-5526 shall be completed by the Medicaid member or their parent, if the member is a minor. The member and the authorized representative must both sign the form. Once completed, the form should be submitted to the Medicaid member's MCO, if for a managed care appeal, or to DHS, if for a state fair hearing. The addresses for each entity are listed in the Appeal and Request for Hearing Form section.

What is a reconsideration process? 

econsideration is a review of the situation by a third party who was not involved in making the initial decision.
When you file an appeal for certain programs, you will need to complete the reconsideration process first.

If your appeal is denied as being premature, the denial letter will instruct you on how to complete the reconsideration process.

NOTE:  The reconsideration process does not apply to child abuse or managed care appeals.

What is the first level review process? 

First level review is a review process that must be exhausted through a managed care organization before an appeal hearing is granted.  The first level review process is mandated by federal regulations.

The managed care organizations include:
  • Amerigroup Iowa Inc.
  • United Healthcare Community Plan
  • Delta Dental of Iowa
  • MCNA Dental
  • Immanual Pathways PACE
  • Siouxland PACE
 
The managed care organization will review information submitted by the Medicaid member and the member’s medical provider to make a decision on the first level review.  Once this process is complete, a notice of decision will be issued by the managed care organization that explains the member, their authorized representative and/or their provider have the right to request a state fair hearing. 
 
Federal regulations allow providers and authorized representatives to file an appeal on behalf of a Medicaid member for managed care appeals when the member has given their express written consent.  Use form 470-5526 to appoint an individual, organization or provider to act on behalf of the Medicaid member during the appeals process.  This form should be completed by the Medicaid member or their parent or guardian, if applicable. 
 
The member and the authorized representative must both sign the form. Once completed, the form should be submitted to the Medicaid member’s MCO or dental carrier, along with the appeal information if for a managed care appeal, or to DHS, if for a state fair hearing.
 
A state fair hearing request is filed with the Department of Human Services Appeals Section.  The Appeals Section will obtain a copy of the first level review outcome letter from the managed care organization.  The Appeals Section will review the request to ensure it was filed timely and that member’s consent has been obtained, if the request was filed by a provider or authorized representative.  If all hearing requirements are met, the appeal file is forwarded to the Department of Inspections and Appeals so an appeal hearing can be scheduled.
 
If the request for a state fair hearing is denied as premature, the Appeals Section will forward the request to the managed care organization so the first-level review process can be initiated.