Medicare Appeals and Grievances
What are Medicare appeal rights?
You have the right to appeal any decision about your Medicare services whether you are in Original Medicare, a Medicare Managed Care plan, or a Medicare Part D prescription drug plan. If your plan refuses payment for an item or service you have been provided, or if you have been denied an item or service you think you need, you may file an appeal.
When you have a grievance or want to file an appeal, it is important to contact your local HICAP office. HICAP may be able to help you resolve your problem before it needs to be appealed. HICAP can also help with the appeal process. Call 1-800-434-0222 to schedule a confidential, one-on-one appointment.
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What are my appeal rights under Original Medicare?
If you are enrolled in Original Medicare, you can file an appeal if you think Medicare should have paid for, or did not pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case. Your appeal rights are printed on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from the company that handles Medicare billing. The notice will also tell you why your bill was not paid and what appeal steps you can take.
For more information, schedule an appointment with HICAP at 1-800-434-0222.
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What are my appeal rights under Medicare Managed Care plans?
If you are in a Medicare Managed Care plan, you can file an appeal if your plan will not pay for, does not allow, or stops a service that you think should be covered or provided. If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. The plan must answer you within 72 hours.
The Medicare Managed Care plan must tell you in writing how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan does not decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. See your plan's membership materials or contact your plan for details about your Medicare appeal rights. See Appeals Process Chart.
For more information about the grievance and appeals process under Medicare Managed Care, see the Medicare Managed Care Appeals & Grievances webpage at www.medicare.gov. You may also call HICAP for a confidential appointment at 1-800-434-0222.
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What are my appeal rights under Medicare Part D prescription drug plans?
If you are in a Medicare prescription drug plan, you can appeal a plan's decision not to provide or pay for a Part D prescription drug that you believe they should cover. The word "provide" includes such things as authorizing prescription drugs, paying for prescription drugs, or continuing to provide a Part D prescription drug that you have already been receiving. The Medicare prescription drug plan must tell you in writing how to request an appeal.
If you request a standard appeal, the plan must answer you within 7 calendar days of receiving your request. If you (or your physician) think your health could be seriously harmed by waiting up to 7 calendar days for a decision, you or your physician can ask for a fast appeal. If the request is approved, the plan sponsor must answer you within 72 hours.
After you file an appeal, the plan will review its decision. If the plan does not decide in your favor, you can appeal the plan's decision to an independent organization that works for Medicare, not for the plan. See your plan's membership materials or contact your plan for details about your appeal rights.
If you have concerns or problems with your plan that are not about providing or paying for a Part D prescription drug, you have a right to file a grievance. For more infomation, schedule an appointment with HICAP at 1-800-434-0222.
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What are my rights when I am in the hospital?
You have rights when you are in the hospital whether you are in Original Medicare or a Medicare Advantage plan. If you are admitted to a hospital that accepts Medicare, you should be given a copy of a publication entitled "An Important Message" within 48 hours. It explains that you have the right to get all the hospital care you need as well as any medically-necessary follow-up care after you are discharged. If you are not given this publication, ask for it. For more information, please call HICAP at 1-800-434-0222.
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What if the hospital wants to discharge me too early?
If you are told you will be discharged from the hospital before you feel well enough to go home, you may file an appeal to Medicare's Quality Improvement Organization (QIO), currently administered through Health Services Advisory Group, Inc. (HSAG). To file the appeal, you or a loved one may call 1-800-841-1602 by noon the day after you have been informed of the discharge plan. There is no charge for this service. Once the appeal is filed, you will neither be discharged nor billed for the time while your situation is investigated. HSAG will notify you and the hospital of the outcome. For more information, please call HICAP at 1-800-434-0222.