Kentucky Medicaid Provider Appeal Form: MCO and Fee-for-Service Filing

To contest a Kentucky Medicaid denial, overpayment demand, or other adverse action, you file one of two things within 30 days of receiving the notice: the standardized Kentucky Medicaid MCO Provider Appeal Request Form if the claim was paid through a managed care organization, or a written dispute resolution meeting (DRM) request to the Department for Medicaid Services if the claim went through fee-for-service. Both are the Kentucky Medicaid provider appeal form for their respective tracks, and both require the denial letter, claim identifiers, and supporting clinical or billing records to be attached.

Pick the Right Form for Your Track

Kentucky processes Medicaid claims through two separate systems, and each has its own appeal form and route.

Fee-for-service (FFS) claims run through the Kentucky Medicaid Management Information System (KYMMIS). Appeals go directly to DMS under 907 KAR 1:671, starting with a written DRM request sent to the branch manager who signed your determination letter.¹

Managed care claims are paid by whichever MCO covers the member, and disputes start with that MCO’s internal appeal process under 907 KAR 17:010. You use the standardized MCO Provider Appeal Request Form and send it back to the MCO that issued the denial.² An MCO appeal sent to DMS, or a DMS appeal sent to an MCO, will not preserve your rights. Check the denial letter to confirm which entity issued it before you pick the form.

Filling Out the MCO Provider Appeal Request Form

The same standardized form works across all contracted Kentucky Medicaid MCOs. Download it from your MCO’s provider portal. The fields to complete:

MCO selection. Check the box for the plan that issued the denial.
Contact information for the person filing the appeal: name, phone, email, and relationship to the provider if filing on someone else’s behalf.
Provider identification: name, NPI, address, and county.
Issue type. Check whether the appeal involves a payment or claim issue (include the claim number and dates of service), an authorization issue (pre-service or post-service), a contract dispute, or another category.
Expedited request. Mark yes if the standard timeline would jeopardize the member’s health, and explain why.
Detail narrative. Describe the issue as fully as you can: why the denial was wrong, what clinical documentation supports your position, and which billing codes or prior authorization numbers apply.
Signature and date.

Attach the denial letter and any related correspondence.² One trap worth flagging: claims denied specifically for missing documentation — consent forms, invoices, itemized bills — are generally not treated as appealable by MCOs and may need to be resubmitted rather than appealed.

The standardized form states appeals must be filed within 30 days of the MCO’s action.² Some MCOs allow longer in their own provider manuals — Humana states 60 calendar days from the date of the notice or denial.³ Filing within 30 days is the safe rule across all plans.

Filing a Fee-for-Service Dispute Resolution Meeting Request

There is no fill-in-the-blank state form for the FFS track. You write a letter (DMS makes appeal-related forms available on the CHFS Medicaid Assistance Program forms page) and send it to the branch manager identified on your adverse determination letter. Under 907 KAR 1:671, the written request must:

Identify each specific issue in dispute.
State why the department’s decision is wrong.
Include supporting documentation.
List the names, mailing addresses, and phone numbers of anyone who will attend the meeting on your behalf.¹

Include the Internal Control Number (ICN) from your remittance advice for each disputed claim, the dollar amounts, and the dates of service. Those details let the reviewer pull up the transactions in KYMMIS. A request that only says “we disagree” without tying the argument to specific claims, codes, or regulations gives the department nothing to review.

You do not have to attend in person. The regulation lets you submit documentation in writing instead of holding a face-to-face meeting, or ask that the meeting be conducted by phone.¹

The 30-day deadline is measured from the date you received the notice, not the date printed on it. Miss it and the determination becomes final.

Supporting Documents to Attach

The strength of either appeal depends on the package you attach. Build it around these categories:

The adverse action notice itself — the denial letter, recoupment demand, or explanation of benefits that triggered the appeal.
Remittance advices showing the ICNs and payment details for each disputed claim.
Clinical records: medical records, chart notes, or treatment plans showing the service was medically necessary and properly coded.
Prior authorization approval letters or authorization numbers if the service required prior authorization.
Billing records: CMS-1500 or UB-04 claim forms showing the codes submitted, plus any corrected claims if coding errors are part of the dispute.

Organize the attachments so each disputed claim has its own set of supporting records. Reviewers handle many appeals at once, and a package that is easy to follow gets a more thorough read.

How and Where to Submit

For an MCO appeal, submit the completed form and attachments to the MCO that issued the denial. Each MCO offers phone, fax, and mail options; Humana also accepts appeals through the provider’s secure Availity account.³ The MCO’s contact information appears on the denial letter and on the form.

For an FFS appeal, the DRM request goes to the branch manager named on your determination letter. If a later formal administrative hearing is needed, that request goes to:

Office of the Commissioner
Department for Medicaid Services
Cabinet for Health and Family Services
275 East Main Street, 6th Floor
Frankfort, KY 40621⁴

Whichever method you use, get proof of delivery. Certified mail with return receipt gives you a paper trail. A fax should go with a cover sheet, and keep the confirmation page. Portal submissions usually generate a tracking number; save it permanently. Filing on time but being unable to prove it is a common and avoidable loss.

Why the Deadline Matters: Recoupment Stays

A timely-filed FFS appeal stays recoupment. Under 907 KAR 1:671, Section 2(10)(b), DMS must pause recoupment activities on the disputed issues once a valid appeal is on file, and the pause lasts through the final administrative decision.¹ File a day late and the recoupment proceeds without an automatic stay.

The stay does not extend into circuit court. If the case moves to judicial review, recoupment resumes unless the court grants a separate stay under KRS 13B.140(4).¹ MCO appeals are governed by each MCO’s contract and provider manual rather than 907 KAR 1:671, so check your MCO’s specific terms on whether collection pauses during appeal.

What Happens After You File

On the FFS side, DMS holds the dispute resolution meeting (or accepts your written submission in lieu of one) and issues a written decision to uphold, rescind, or modify the original action. If the decision is unfavorable, you have 30 calendar days from receipt to request a formal administrative hearing.¹ Only issues you raised at the DRM can be considered at the hearing, so raise everything now.

On the MCO side, the plan conducts its internal review, evaluates your documentation and the original denial rationale, and issues a written decision. If that decision is still unfavorable, you have 60 calendar days to request an external independent third-party review under 907 KAR 17:035.⁵ That external review must be completed before you can request an administrative hearing under 907 KAR 17:040, and judicial review in circuit court is available after the hearing officer issues a final order.⁶

1
Kentucky Legislative Research Commission. 907 KAR 1:671 – Conditions of Medicaid Provider Participation; Withholding Overpayments, Administrative Appeal Process, and Sanctions
2
Anthem. Kentucky Medicaid MCO Provider Appeal Request Form
3
Humana. Kentucky Medicaid – Provider Information – Grievances and Appeals
4
Kentucky Medical Management Information System. KYMMIS Contact Information
5
Kentucky Legislative Research Commission. 907 KAR 17:035 – External Independent Third-Party Review
6
Kentucky Legislative Research Commission. 907 KAR 17:040 – Appeal and Administrative Hearing Post External Independent Third-Party Review