Other Important Information – Medicare Appeals and grievances
You Are Protected When You Are In The Hospital
This is true whether you are in Original Medicare or a Medicare Managed Care Plan. If you are admitted to a Medicare participating hospital, you should be given a copy of ‘An Important Message From Medicare’. It explains your rights as a hospital patient. If you are not given one, ask for it.
‘An Important Message From Medicare’ Tells You:
- You have the right to get all of the hospital care that you need, and any follow-up care after you leave the hospital.
- What to do if you think the hospital is making you leave too soon.
If you ask a Quality Improvement Organization (QIO) to review your case, you may be able to stay in the hospital at no charge during the review. The hospital cannot force you to leave before the QIO makes a decision.
Medicare Appeals and Grievances
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 on the back of the Explanation of Medicare Benefits or Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why your bill was not paid and what appeal steps you can take.
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.
Appeal Rights Under Medicare Prescription Drug Plans
If you are in a Medicare Prescription Drug Plan, you can appeal a Plan sponsor’s decision not to provide or pay for a Part D prescription drug that you believe the Plan sponsor should provide or pay for. 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 been getting. The Medicare Prescription Drug Plan must tell you in writing how to request an appeal.
If you request a standard appeal, the Plan sponsor must answer you within 7 calendar days after 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 the Plan sponsor 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 sponsor will review its decision. If the Plan sponsor does not decide in your favor, you can appeal the decision to an independent organization that works for Medicare, not for the Plan sponsor. See your Plan sponsor’s membership materials or contact your Plan sponsor for details about your appeal rights.
If you have concerns or problems with your Plan sponsor that are not about the Plan sponsor providing or paying for a Part D prescription drug, you have a right to file a grievance. For example, if you have difficulties getting through to the Plan sponsor on the telephone, you can file a grievance.