A companion to our DHB-3051 PCS Referral Guide: this reference covers what happens after the paperwork is filed — specifically, what to do when a PCS request comes back denied, reduced, or approved for fewer hours than the beneficiary actually needs. North Carolina uses two different appeal pathways depending on how the beneficiary is enrolled (NC Medicaid Direct fee-for-service versus a managed care health plan), plus a separate reconsideration process for hours that were approved but insufficient. Getting the right track and the right deadline matters — miss the window and the right to appeal that decision is generally lost.
About This Guide
Carolina Home Health Care maintains this reference for the discharge planners, hospital and SNF social workers, and case managers we partner with across the Charlotte and Raleigh metro areas. We built it as a companion to our DHB-3051 referral guide because a denied or reduced PCS request is one of the most common — and most time-sensitive — problems our referral partners run into. Bookmark it; we keep it current.
Which Track Applies to You?
Three different situations require three different responses. The trigger — not the beneficiary's diagnosis or care needs — determines which track to use.
At a Glance
Start by identifying which of these three situations matches what happened, then follow the matching section below.
| Situation | First Step | Deadline |
|---|---|---|
| Approved, but for fewer hours than needed | DHB-3114 Reconsideration Request + supporting documentation, faxed to NC LIFTSS | 31–60 calendar days from the approval notification |
| Denied, terminated, suspended, or reduced — NC Medicaid Direct (fee-for-service) | Hearing Request Form to the Office of Administrative Hearings (OAH) | 30 days from the date on the adverse decision (10 days to also preserve continuation of benefits) |
| Denied, terminated, suspended, or reduced — Managed Care health plan | Internal appeal with the health plan first | 60 days from the Notice of Adverse Benefit Determination; then 120 days to request an OAH State Fair Hearing if still denied |
Managed care applies to beneficiaries enrolled in one of the NC Medicaid Standard Plans or Tailored Plans — Carolina Complete Health, AmeriHealth Caritas, Partners Health Management, Alliance Health, Trillium Health Resources, Vaya Total Care, UnitedHealthcare Community Plan, Healthy Blue, or WellCare of NC. NC Medicaid Direct applies to beneficiaries who remain in the fee-for-service program (not enrolled with one of those health plans). If you are not sure which applies to your patient, check the plan name on their Medicaid card — it is the same plan used to route the original DHB-3051 in our referral guide.
Approved for Fewer Hours Than Requested? Start With Reconsideration
If NC LIFTSS approved PCS but at a lower service level than the beneficiary needs, that is not yet a denial — it is a starting point for a reconsideration request, and it should be tried before jumping to a formal appeal.
DHB-3114 Reconsideration Request Not an appeal
- Form
- DHB-3114 Request for Reconsideration of PCS Authorization, plus supporting documentation
- Window
- No earlier than 31 calendar days and no later than 60 calendar days from the date of the approval notification
- Submit
- Fax to NC LIFTSS at 1-833-521-2626
- What to include
- Documentation explaining why additional hours are needed, which specific ADLs and tasks are not being met with the current authorization, and why the prior assessment did not accurately capture the beneficiary's functional needs
- Turnaround
- 3–5 business days once the completed request is received; reviewed by a nurse reviewer
- Questions
- NC LIFTSS 1-833-522-5429; NC Medicaid Reconsideration staff 919-855-4360
Two outcomes are possible. If the nurse reviewer awards additional hours, that is an approval — there is no adverse notice and no appeal rights involved, but the provider will need a new service plan reflecting the increase before it takes prior-approval effect. If the reviewer determines the originally authorized hours are sufficient, that decision is an adverse decision with formal appeal rights — move to the NC Medicaid Direct or Managed Care track below, whichever applies to the beneficiary.
NC Medicaid Direct: How to Appeal a Denial
This track applies when NC Medicaid Direct (not a managed care health plan) issues an adverse decision — a denial, termination, suspension, or reduction of PCS.
Get the Hearing Request Form
It is included with the adverse decision notice. If it was not received or was misplaced, call the DHB Appeals line at 888-245-0179 to request one.
File With the Office of Administrative Hearings (OAH)
Complete and return the Hearing Request Form to OAH within 30 days of the date on the adverse decision notice. Mailing address and fax number are printed on the form itself; faxing to both OAH and DHB is usually the fastest route. Keep proof of filing.
Ask for Continuation of Benefits (If Wanted)
File within 10 days of the date on the notice to keep PCS hours unchanged while the appeal is pending, with no break in services.
Mediation
A mediator contacts the beneficiary within 25 days of filing to schedule an informal discussion — usually by phone — with a representative from NC Medicaid's Division of Health Benefits (DHB). Participation is common and can resolve the dispute without a full hearing.
Contested Case Hearing (If Unresolved)
If mediation does not resolve the dispute, an administrative law judge at OAH hears the case and issues a decision.
NC Medicaid Direct Appeal Contacts
DHB Appeals (missing Hearing Request Form): 888-245-0179
Office of Administrative Hearings: 984-236-1860 (phone) | 984-236-1850 (fax) | 1711 New Hope Church Road, Raleigh, NC 27609
Case file request (via Assistant Attorney General): 919-716-6855 — have the case number ready
Managed Care Health Plan: How to Appeal a Denial
This track applies when the beneficiary is enrolled in an NC Medicaid managed care health plan and that plan issues a Notice of Adverse Benefit Determination. Unlike NC Medicaid Direct, managed care enrollees must appeal to the health plan first before OAH gets involved.
File the Plan's Internal Appeal
Submit the Appeal Request Form included with the notice — by mail, fax, or phone, per the instructions on the letter — within 60 days of the mailing date of the Notice of Adverse Benefit Determination.
Ask for Continuation of Benefits (If Wanted)
Request it within 10 calendar days of the notice date, or before the change takes effect — whichever comes first.
Plan Issues a Notice of Resolution
The health plan must resolve the appeal within 30 days of receiving the request (extensions are possible under 42 C.F.R. § 438.408). An expedited appeal is available when a delay would seriously harm the beneficiary's health.
Request an OAH State Fair Hearing (If Still Denied)
If the plan's Notice of Resolution does not resolve the issue, complete the State Fair Hearing Request Form included with that notice and return it to both OAH and the health plan within 120 days of the Notice of Resolution's mailing date.
Managed Care Appeal Contacts
Trillium Health Resources: 1-877-685-2415
Vaya Health: 1-800-962-9003
AmeriHealth Caritas NC: 1-855-375-8811 (TTY 1-866-209-6421)
WellCare of NC: 1-866-799-5318
Carolina Complete, Partners, Alliance, UnitedHealthcare, Healthy Blue: use the Member Services number printed on the Notice of Adverse Benefit Determination letter
NC Medicaid Managed Care Ombudsman (free, independent help with any plan's appeal or Fair Hearing process): 1-877-201-3750
Office of Administrative Hearings (State Fair Hearing): 984-236-1860 (phone) | 984-236-1850 (fax)
Continuation of Benefits: Don't Miss the 10-Day Window
Across both tracks, the mechanism to keep PCS hours unchanged while an appeal is decided is called continuation of benefits (sometimes called "aid continuing"). The details differ slightly by track, but the core rule is the same:
- ✓NC Medicaid Direct: file the Hearing Request Form within 10 days of the adverse decision notice.
- ✓Managed care: request continuation of benefits within 10 calendar days of the notice date, or before the effective date — whichever is earlier.
- ✓Only the beneficiary or their authorized representative can make this request — a home care provider or case worker cannot request it on the beneficiary's behalf, though they can remind the beneficiary or guardian to make the request in time.
- ✓If the appeal is decided in the beneficiary's favor, nothing further is owed. If it is decided against them, they may be billed for services received during the appeal.
Mediation and the OAH Hearing
For NC Medicaid Direct appeals, mediation is an informal, non-binding conversation — typically by phone — between the beneficiary (or their representative) and a DHB representative, with a neutral mediator present. A doctor, nurse, home care provider, case manager, or family member can join to explain the beneficiary's care needs. It happens before a formal hearing and often resolves the dispute without one.
If the case proceeds to a hearing — a contested case hearing at OAH for NC Medicaid Direct, or a State Fair Hearing for managed care — an administrative law judge who is independent of both NC Medicaid and the health plan reviews the evidence, hears from both sides, and issues a decision. Representation by an attorney is allowed but not required; many beneficiaries represent themselves or are supported by a family member, case worker, or advocate.
Documentation That Strengthens an Appeal
Whichever track applies, a well-documented appeal moves faster and has a better chance of success. In our experience helping referral partners through this process, the strongest appeals typically include:
- ✓A physician or practitioner letter that specifically ties the diagnosis to the ADL deficit and describes why the currently authorized hours fall short
- ✓A copy of the original DHB-3051 or DHB-3114 and the adverse decision or Notice of Adverse Benefit Determination itself
- ✓A specific, task-by-task description of unmet needs (for example: "requires two-person assist for toileting three times daily, currently authorized hours only cover one visit")
- ✓Any incident reports, fall history, hospitalization records, or caregiver notes that support the case
- ✓A written record of every date something was filed and every deadline, since the review process moves through several time-sensitive steps
Beneficiaries and their representatives have the right to request a copy of the file the plan or NC Medicaid used to make its decision — for NC Medicaid Direct, that request goes through the Assistant Attorney General handling the case; for managed care, it comes from the plan directly, free of charge.
How Carolina Home Health Care Can Help
We work with discharge planners, social workers, and case managers across the Charlotte and Raleigh metro areas every week, and appeals are a regular part of that work when hours don't match a patient's real needs. When a patient has chosen us as their provider, we can help document unmet ADL needs from what our caregivers observe day to day, provide records that support a reconsideration or appeal, and coordinate with the beneficiary or guardian on deadlines. We are not attorneys and this is not legal representation, but we know the process well and are glad to help however we can.
Referral & Support Contact Information
Charlotte Office: (704) 548-8949 | Fax: (704) 594-9670
Raleigh Office: (919) 751-4837 | Fax: (919) 921-8017
Email: info@carolinahomehealthcare.com
Web: www.carolinahomehealthcare.com
Frequently Asked Questions
What is the difference between a PCS reconsideration request and a PCS appeal?
A reconsideration request (DHB-3114) is for when PCS was approved but at fewer hours than needed; it is not an adverse action. An appeal follows a formal denial, termination, suspension, or reduction, and runs through either the NC Medicaid Direct/OAH process or the managed care health plan process, depending on enrollment.
How long do I have to appeal an NC Medicaid Direct PCS denial?
File the Hearing Request Form with OAH within 30 days of the date on the adverse decision. Filing within 10 days also preserves continuation of benefits without a break in services.
How long do I have to appeal a managed care health plan's PCS decision?
60 days from the Notice of Adverse Benefit Determination to appeal to the plan directly, then 120 days from the plan's Notice of Resolution to request an OAH State Fair Hearing if still denied.
How do I keep PCS hours from stopping while I appeal?
Request continuation of benefits within 10 days (Direct) or 10 calendar days / before the effective date (managed care). Only the beneficiary or their authorized representative can request it, and the beneficiary may be billed for services received during the appeal if it is ultimately unsuccessful.
What is mediation and do I have to go?
For NC Medicaid Direct appeals, a mediator contacts you within 25 days of filing to schedule an informal, usually phone-based, discussion with a DHB representative. It's not required but often resolves the issue faster than a hearing. Managed care appeals go from the plan's internal review straight to an OAH State Fair Hearing instead.
What happens at an OAH hearing?
An independent administrative law judge reviews the case and any new documentation, hears from the beneficiary or their representative and from NC Medicaid or the health plan, and issues a decision.
Can a home care agency or case worker file the appeal for the beneficiary?
The form must be signed by the beneficiary or their legal guardian. A case worker or agency can help with documentation and support the case, but can't sign or file on the beneficiary's behalf unless formally authorized as their representative.
What if the deadline to appeal is missed?
The right to appeal that specific decision is generally lost. The provider can still submit a new DHB-3051 as a Change of Status request if the beneficiary's condition has changed, but that restarts the assessment process rather than challenging the original decision.