HOW  TO  ASK  FOR  A  FAIR  HEARING

Your Right to Appeal:  If you disagree with the action by MassHealth, you have 
the right to appeal and ask for a fair hearing before an impartial hearing 
officer. The Board of Hearings must get your fair hearing request form no later 
than 30 calendar days from the date you got MassHealth's official written notice 
telling you of the action to be taken.

If you want to ask for a fair hearing because MassHealth did not take action on 
your application or on your request for service, MassHealth did not send you a 
written notice of the action to be taken, or a MassHealth employee's behavior 
toward you was coercive or improper, the Board of Hearings must get your fair 
hearing request form no later than 120 calendar days from the date of 
your application or your request for service, MassHealth's action, or the 
MassHealth employee's improper behavior.

How to Appeal:  To ask for a fair hearing, fill out the fair hearing request 
form (be sure to fill out Section II-Reason for Appeal) and send one copy with a 
copy of the MassHealth official written notice to: Board of Hearings, Office of 
Medicaid, 100 Hancock Street, 6th Floor, Quincy, MA 02171 or fax them to 617-
847-1204. Please keep one copy of the fair hearing request form for your 
information.

If You Are Now Getting MassHealth:  If the Board of Hearings gets your fair 
hearing request form before the date the action is taken or, if later, within 10 
calendar days of the mailing date of MassHealth's written notice to you, you 
will keep getting MassHealth until a decision is made on your appeal. If you get 
MassHealth during your appeal, and then lose your appeal, you may have 
to pay MassHealth back for the cost of MassHealth benefits that you got during 
this time period. If you do not want to keep getting MassHealth during your 
appeal, please check Box A in Section III on the fair hearing request form. If 
you do not get MassHealth during your appeal, and then you win your appeal, 
MassHealth will restore your MassHealth benefits.

Date of Fair Hearing: At least 10 calendar days before the fair hearing, the 
Board of Hearings will send you a notice telling you the date, time, and place 
of the hearing. This will give you time to get ready for the hearing. If you 
want to have a fair hearing scheduled as soon as possible, check Box B in 
Section III on the fair hearing request form for an expedited hearing. If you 
have good cause for not being able to come to the hearing, or if you need a 
telephone hearing, you must call the Board of Hearings at 617-847-1200 or 1-800-
655-0338 before the hearing date. If you do not reschedule or appear on time at 
the hearing without documented good cause, your appeal will be dismissed.

Your Right to Be Helped at the Hearing:  At the hearing, you may represent 
yourself or be represented by a lawyer or other representative at your own 
expense. You may contact a local legal service or community agency to get advice 
or representation at no cost. To get information about legal service or 
community agencies, call the MassHealth Customer Service Center at 1-
800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing 
loss).

If You Need an Interpreter or an Assistive Device:  If you do not understand 
English and/or are hearing or sight impaired, the Board of Hearings will provide 
an interpreter and/or assistive device for you at the hearing. Please check 
either Box C or D, or both, in Section III on the fair hearing request form if 
you need an interpreter or assistive device, or call the Board of Hearings 
at 617-847-1200 or 1-800-655-0338 at least five business days before the 
hearing.

Your Right to Review Your Case File:  You and/or your representative can review 
your MassHealth case file before the hearing. To do this, call a MassHealth 
Enrollment Center at 1-888-665-9993  (TTY:  1-888-665-9997 for people with 
partial or total hearing loss) before the fair hearing.
Your MassHealth case file is not kept at the Board of Hearings.

Your Right to Ask to Subpoena Witnesses, and Your Right to Question:  You or 
your representative may write to the Board of Hearings to ask that witnesses or 
documents be subpoenaed to the hearing.You or your representative may present 
evidence and cross-examine witnesses at the hearing. The hearing officer will 
make a decision based on all evidence presented at the fair hearing.

NONDISCRIMINATION NOTICE FOR APPLICANTS AND MEMBERS:  Under federal and 
state law, MassHealth does not discriminate on the basis of race, color, sex, 
sexual orientation, national origin, religion, creed, age, health status, or 
handicap.

FAIR  HEARING  REQUEST  FORM 	

FILL OUT ALL SECTIONS THAT APPLY.
PRINT CLEARLY.

SECTION I: Applicant/Member Information 

Name of Applicant or Member:
Address:
Telephone No.: (         )
MassHealth I.D. or Social Security Number:Cardholder's Name on MassHealth card 
(if different):

SECTION II: Reason for Appeal

I,                                                                              
,
want a fair hearing because:	

Signature:
Date:

SECTION III: Appeal Information (Check the boxes that apply to you.)

A.  I do not want to keep getting MassHealth during the appeal process.
B.  I want an expedited hearing.
C.  I need an interpreter (what language?:)to be provided by the Board of 
Hearings. 
D.  I need an assistive device to be provided by theBoard of Hearings.  
(Describe what type of 
assistive device you need.  For example: American Sign Language):

SECTION IV: Appeal Representative, if any

My appeal representative is:
Title:
Address:
Telephone No.: (         )





FHR-1 (Rev. 09/10)