A Medicaid or Medicare denial is an administrative decision, not a medical one. The reviewer who denied your claim may have spent minutes on a file representing months of your medical history. The appeals process exists precisely because initial denials are reversed at rates that would surprise most applicants. If you have received a MassHealth denial, a Medicare coverage denial, or a notice terminating services you depend on, the question is not whether the decision is correct. The question is whether the evidence supporting your claim was properly considered and whether the correct legal framework was applied. A benefits appeal attorney can identify where the initial review went wrong and build a case for reversal. Strict deadlines govern every stage of a MassHealth denial appeal, and every level of the Medicare process, and missed timelines can permanently foreclose relief.
How We Help with Medicaid and Medicare Benefit Appeals
Medicaid and Medicare appeals operate under distinct procedural frameworks, and effective representation requires fluency in both. For MassHealth denials in Massachusetts, the appeal route runs through the Board of Hearings at the Office of Medicaid, where a fair hearing examiner reviews the agency’s determination. We prepare hearing presentations that reframe the evidentiary record, obtaining updated medical documentation, securing physician statements addressing medical necessity, and identifying procedural errors in the initial review.
Medicare appeals follow a five-level structure: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review in federal court. Each level imposes its own deadline and evidentiary requirements. We tell our clients that the ALJ hearing is often where meritorious claims are finally recognized, because it is the first stage where a claimant can present testimony and cross-examine witnesses.
Common denial reasons include determinations that a service is not medically necessary, that eligibility criteria are unmet, or that coverage has been terminated. Whether the dispute involves a Medicaid eligibility appeal or a Medicare coverage denial, the outcome depends on documentation. We work with treating physicians and develop submissions that speak directly to the regulatory criteria the adjudicator applies.
Why Clients Choose Cohen Cleary
At Cohen Cleary, our practice teams combine deep subject-matter experience with disciplined execution and responsive client service. We do not take a one-size-fits-all approach. Every matter is handled with careful preparation, clear communication, and a strategy tailored to the client’s goals and the realities of the forum.
Clients choose Cohen Cleary because we deliver:
Practice-Focused Legal Experience
Our attorneys work in defined practice areas, allowing us to develop practical insight into the legal, procedural, and regulatory nuances that matter most in each case. This focus allows us to anticipate issues, avoid unnecessary delays, and position matters for efficient resolution.
Clear Guidance and Proactive Communication
We prioritize clarity at every stage. Clients receive straightforward explanations of their options, timely updates on developments, and practical advice grounded in real-world outcomes.
Strategic Advocacy with Trial Readiness
Whether a matter calls for negotiation, mediation, or litigation, our attorneys prepare every case with discipline and foresight. We pursue efficient resolution when possible and are fully prepared to advocate aggressively when necessary to protect our clients’ interests.
Regional Knowledge and Local Presence
With offices throughout Massachusetts and experience across New England courts and agencies, we bring local insight and regional reach to every matter.
Client-Centered Service
We treat every matter with urgency and respect. Our clients rely on us for responsive service, sound judgment, and steady counsel through complex legal challenges.
In our Medicaid and Medicare appeals work, this approach helps clients challenge benefit denials with clarity, efficiency, and confidence.
Our Approach to the MassHealth Appeal Process and Medicare Hearings
Every benefits appeal begins with a detailed review of the denial notice and the underlying administrative record. We identify the specific regulatory basis for the denial and assess where the initial review failed to account for available evidence. From there, we develop a targeted strategy: gathering additional medical documentation, coordinating with treating providers, and preparing written submissions or hearing presentations calibrated to the standards the adjudicator will apply. We tell our clients that the first priority after receiving a denial notice is preserving continuation of benefits, not just filing the appeal. Acting quickly protects both.
Medicaid and Medicare Appeal Representation Across New England
Because Medicaid is state-administered and Medicare appeals involve both federal and regional components, benefits denial cases require familiarity with the procedural landscape in each jurisdiction. Cohen Cleary represents individuals appealing benefit denials across New England, with particular concentration in the following areas:
- Massachusetts MassHealth fair hearings before the Board of Hearings at the Office of Medicaid
- Medicare appeals at all five levels, including ALJ hearings conducted through the Office of Medicare Hearings and Appeals
- State-specific Medicaid appeal procedures throughout New England, where program administration and hearing processes vary by jurisdiction
Our offices in Taunton and Plymouth serve as the firm’s operational base, and our attorneys practice in every state where the firm maintains active licensure.
Schedule a Consultation With a Massachusetts Medicaid and Medicare Denial Appeal Attorney
If you have received a Medicaid or Medicare denial notice, the appeal window is already running. Contact Cohen Cleary to discuss your options and determine the strongest path forward for your benefits appeal. A Massachusetts Medicaid appeal attorney at our Taunton or Plymouth office can evaluate your case and advise on next steps.
Frequently Asked Questions About Medicaid and Medicare Denial Appeals
Can I appeal a MassHealth denial, and how long do I have?
Yes. MassHealth applicants and beneficiaries have the right to request a fair hearing through the Board of Hearings. In Massachusetts, the request must generally be filed within 60 days of the denial notice, though timelines vary depending on the type of denial. Understanding the MassHealth appeal process and filing promptly is critical, as a timely appeal may also preserve your right to continue receiving benefits while the appeal is pending. A MassHealth denial lawyer can evaluate whether your case qualifies for expedited review.
What are the levels of a Medicare appeal?
Medicare appeals proceed through five levels: redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor (QIC), a hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and judicial review in federal court. Each level has its own deadline, typically 60 to 120 days, depending on the stage. The ALJ hearing is often the most consequential, as it is the first opportunity to present live testimony and challenge the basis for the denial directly. An experienced Medicare appeal lawyer can make a significant difference at every stage.
What are the most common reasons for Medicaid or Medicare denials?
Denials frequently arise from determinations that a service is not medically necessary, that the applicant does not meet financial or clinical eligibility criteria, or that coverage has been terminated due to changed circumstances. In many cases, the initial reviewer did not have access to complete medical records or failed to apply the correct regulatory standard. A well-prepared appeal can address these gaps.
Can I keep receiving benefits while my appeal is pending?
In certain circumstances, yes. For MassHealth, if you request a fair hearing before the effective date of a reduction or termination, benefits may continue at the current level until the hearing decision is issued. Medicare continuation of benefits depends on the appeal level and timing of the request. We advise clients to act immediately upon receiving a denial notice so that continuation options are preserved.
