Last Updated October 2023
This Fact Sheet is available for download in the following languages:
- English: Family Guide to Medicaid Managed Care Appeals
- Spanish Español: Guía Familiar para Apelaciones de Atención Administrada de Medicaid
Table of Contents
- Table of Contents
- Step 1
- Step 2
- Step 3
- Step 4
- Step 5
- Step 6
- For More Information
- Related Fact Sheets and Information
Step 1
Get a prescription from your child’s doctor for a recommended, medically necessary treatment. For example, a developmental evaluation or a therapy service require a prescription.
A prescription is also needed for durable medical equipment as well as for some supplies or over-the- counter medications for children.
Step 2
If you do not have parental employer insurance and your child is enrolled in an All Kids (Medicaid) Managed Care Organization contact your child’s care coordinator by calling the toll-free customer service number on your child’s insurance card. Important – if your child does not yet have a care coordinator, you can request one by calling the same toll-free customer service number. Illinois Health Choice (Medicaid Managed Care) organizations include: Blue Cross/Blue Shield: 877-860-2837; Aetna Better Health: 866-329-4701; Molina: 855-687-7861; Meridian: 866-606-3700 and County Care: 312-864-8200).
- Tell the care coordinator that Dr. ______ has prescribed the following service ______ at the last office visit.
- Ask for a referral to a provider of this service who is “in-network” with the health plan.
Step 3
If you receive a list of in-network therapy providers, you will need to call each one and request an appointment for your child. You need to keep a record of each call which you make and the response that you receive:
- Provider name
- Telephone number
- Date and time of your call
- Name of person you spoke with
- Outcome of your call (for example: my child got an appointment, I was told that there is a waiting list, I was told that provider does not accept Medicaid, I was told that provider is no longer “in network” with the health plan, other)
Step 4
If the care coordinator informs you that the health plan does not have a provider for the prescribed services, or that you can only be referred to a provider who has a long waiting list (or any other reason that your child cannot receive the prescribed service), then you may choose to file a grievance with the health plan according to the rules in your Member Handbook; you may also choose to place your child on the waiting list.
Step 5
If you do not have a member handbook, you can ask the Care Coordinator to send one to you in any language and/or format required. You can also look at the Member Handbook on the health plan’s website.
Step 6
If you do not agree with the decision which the health plan made in response to your grievance, then you can file an appeal with the Illinois Department of Healthcare and Family Services. Here is information regarding how to do this if you are enrolled in a Medicaid Managed Care Organization (MCO):
- Appeal information from HFS, the state Medicaid agency
- Appeal information from the Department of Human Services
Be sure to keep copies of all documents related to your grievance and/or appeal.
If seeking ABA services for a child with autism spectrum disorder, enrolled in a Medicaid Managed Care Organization, see: https://ilasd.com/resources/insurance-appeals-and-denials/
For More Information
Please contact The Arc of Illinois Family-to-Family Health Information Center at 866-931-1110 or Illinois Life Span Program at 800-588-7002 if you have any questions or need more information.
Related Fact Sheets and Information
- General Medicaid Questions [English and Spanish]