How to appeal ALTCS Denial?

So you’ve been denied; you’re not alone.ALTCS denies about 79% of all applications.

Technically, you have 60 days to appeal a decision, so you need to act quickly if you decide to appeal the ALTCS denial and you want to know how to appeal ALTCS denial. But before you decide to take the appeal path, consider the following.

Here are the top six reasons ALTCS denies claims they include:

1. The applicant is Not Medically Eligible
2. The applicant is Not Financially Eligible
3. The applicant Didn’t meet deadlines during the application process
4. Not providing the requested information
5. The applicant’s claim is abandoned
6. Errors made by ALTCS Caseworkers

Let’s break these down into the cause for the denial and if an appeal makes sense.

 1. The applicant is Not Medically Eligible

Medical eligibility starts with the Preadmission Screening or PAS Assessment. The problem with the PAS assessment is it is somewhat a subjective process.

An assessor from the State of Arizona ALTCS office performs the assessment. The assessor is usually a social worker or nurse. They have defined guidelines for conducting the examination, but it is still up to them to score the applicant’s responses.

A human being does the PAS assessment; this person often has a large caseload and is under pressure to complete the evaluation quickly and go on to the next. The assessor is a human, just like you and I, with their style and personal experiences. This human element will cause the score to differ from one assessor to another.

Therefore appealing a medical denial may make sense in some instances.

The Appeal starts with a prehearing, where the medical assessor and their supervisor review the case, allowing the assessor to re-review the information obtained. 

They can reverse the decision at that time or refer it to a full hearing.

I have appealed many medical assessments with a 100% success outcome. If you have been denied medically and would like to have professional assistance with an appeal, call my office to discuss your case.

2. The applicant is Not Financially Eligible

Financial eligibility has clear “Brightline Limits.”  An applicant can have up to $2000 in total countable assets. They can have one car, personal items, pre-paid burial plan inside a “Funeral Trust”, $1,500 set aside for the funeral, and own a home unless ownership is held in a trust. 

A married couple that is both are applying can have $3000 in cash assets, plus all the above.

A married couple where only one spouse is applying can have $27,480 plus the $2000 for a total of $29,480, plus one car, personal items, pre-paid burial plan inside a “Funeral Trust,” $1,500 set aside for the funeral, and home unless ownership is in a trust. 

That is pretty clear if you ask me. So if you are over those limits, you will be denied, Period!

Nothing to appeal; your denial will stand!

Your best bet is to use some of the excess funds to hire a Certified Medicaid Planner to help you re-apply and have the assets adequately set up before you start the new application.

But what if it’s another reason you’re denied like the caseworker counted an unavailable asset?

An Unavailable Asset has no value. It can not be sold and converted to cash. Examples of this may be a car that is a wreck or a “Time Share” that can’t be sold. There are fixes for both and other assets.

However, appealing a case may not be necessary, simply contacting the caseworker’s supervisor and discussing the issue may resolve the matter, and the case could be approved.

Even if this fails, it might be better to fix the issue and re-apply rather than appeal the denial.

Here again, if you call our office and discuss this with one of our “Certified Medicaid Planners.” They can help guide your decision. (se habla español aquí)

3. The applicant did not meet deadlines during the application process

Well, not much to appeal here.

You missed a deadline. Missing deadlines may be the number one reason people are denied! ALTCS is on a strict timeline that they must meet, and so do you.

Once opened, you have 15 days to provide the requested information. It can be helpful to ask to have the application and requirements emailed to you rather than mailed via US Mail. Emailing saves precious time that regular mail will take up.

The caseworkers will not readily share the fact with you that you can request a five-day extension, and in fact, they sometimes act like they are doing a favor when they approve it. But it is the law! Most are unaware that the rules under Medicaid allow you to request a five-day extension.

They are also required to give you an additional 15 days if they ask for information on something they have not previously requested. Again this is the rule under Medicaid!

But here is the reality, the caseworker has some leeway to allow extra time informally, which is much better than trying to do everything by the book. The book can slam shut on you too!

I try my best to develop a cordial relationship with the ALTCS caseworker.

But beware, you are not lulled into a false sense of security. Remember they work for the State of Arizona – AHCCCS, not you!

The best advice is to stay on track and provide everything requested so you are not denied.

If a request is not valid, talk with the caseworker to better understand the request. On multiple occasions, I have had a financial caseworker ask for information on a bank account that never existed, so the request is invalid. A “Statement of Fact” can clear this up. A statement of fact is an affidavit that ALTCS uses to clear up these issues.

Last word here, a Certified Medicaid Planner can help. They have experience dealing with deadlines and can anticipate items the caseworker may want. 

4. Not providing the requested information

ALTCS will make a request for various information needed to approve the case. Such as bank and stock trade account information, car value, marriage certificate, Medicare insurance information,  and current month income verification from all sources.

ALTCS will ask for bank statements for the month of application, and they may ask for statements from specific months going back five years.

A bank statement is ALL pages of the statement, not just page one. Bank statements will say pages 1 of 4 or 1 of 6. That means that there is more than one page, and ALTCS wants all pages of the statement.

Recently I was working on a case and the daughter of the applicant was having trouble understanding the needed requirements, like the request for the entire bank statement.

In her frustration, she said, “You can just appeal the case if my Mom is denied!”  I said, “Appeal what?” “You not wanting to provide the information is not grounds for an appeal.”

Those trying to apply without professional help can call and discuss the request with the caseworker or their supervisor to get clarification.

As Certified Medicaid Planners, we know if it is valid or not, which will keep the claim from being needlessly denied to begin with and help you understand the reason for the request.

They can also help properly prepare the case and reopen it so it is approved, not denied.

5. The applicant’s claim is abandoned

ALTCS claims are often left incomplete.

Maybe a well-meaning social worker starts an application with no actual knowledge of the applicant’s personal financial information.

Once the applicant learns that a social worker did this, they choose not to respond to the request from ALTCS, knowing the claim will be denied anyway.

Another reason may be that the applicant cannot gather needed requirements because they are in hospital or rehab and do not have family helping them through the process.

Here there is nothing to appeal, just prepare the claim properly in advance and re-open it once you are ready.

The good news is that at least you know what the requirements will be exactly when you re-apply.

Read about Arizona Long Term Care System(ALTCS).

Errors made by ALTCS Case Worker

Caseworkers make mistakes. Yes, hard to believe, I know, LOL!

I recently had a case denied because the assets were too high to qualify. The problem was the caseworker calculated the assets based on a single individual, not a married couple.

I took one look at that and called the caseworker and pointed out the apparent error, and she turned around and approved it.

I had another case that was denied. The caseworker denied it because the applicant gifted $142,000 to their son. I remember that I called the caseworker and said why did you deny the case?

She replied, “Gifting causes a penalty!” I was shocked, “I said that is not grounds for a denial!” I told her she could reverse the denial and approve it, or I’ll discuss this with her supervisor. She approved the case.

Appealing causes animosity between you and the caseworker. They don’t like to have one of their decisions appealed and may turn around and find some erroneous reason to deny the case anyway. Please note the pattern here, 98% of issues can resolve without an appeal.

It is best to stay out of the fray and work with the caseworker and their supervisor.

Better yet, hire a professional to help you. The cost of loss of time when a claim is prepared improperly is far more than the cost to hire a Certified Medicaid Planner.

In conclusion, it sounds forceful to say, “I will appeal!” But in the long run, it might be wiser to correct the issue and re-apply—just a thought. I hope you got an understanding of how to appeal ALTCS denial.

Learn about how long does it take to be approved for ALTCS.