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Medicare Appeals and Grievances Your Medicare Appeal Rights:

You have the right to appeal any decision about your Medicare services. This is true whether you are in Original Medicare, a Medicare managed care plan, or a Medicare prescription drug plan. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.

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 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.

For more information about the grievance, organization determination, and appeals processes under Medicare Managed Care, see the Medicare Managed Care Appeals & Grievances webpage on the cms.gov website: http://www.cms.hhs.gov/MMCAG

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 plan sponsor’s 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.

For detailed information about the grievance, coverage determination, and appeals processes under Medicare Part D, and the forms you and/or your physician should use to make or support requests under Medicare Part D, see the Medicare Prescription Drug Appeals & Grievances webpage on the cms.gov website: http://www.cms.hhs.gov/MedPrescriptDrugApplGriev

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.

The Message 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 have questions about this, call 1-800-MEDICARE. 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. View and Download Medicare Appeals Forms If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing. You can fill out the “1-800 Medicare Authorization to Disclose Personal Health Information” form. Call 1-800-MEDICARE (1-800-633-4227) to get a copy of the form, or you can download the form in the Medicare Online Forms section of this web site.

2 Responses to “Medicare Appeals and Grievances”

  • Bardero says:

    NCHS Data Linked to Medicare Enrollment and Claims Files

    NCHS has developed a record linkage program designed to maximize the scientific value of the Center’s population-based surveys. NCHS is currently linking various NCHS surveys with Medicare enrollment and claims records collected from the Centers for Medicare and Medicaid Services (CMS).

    Linkage of the NCHS survey participants with the CMS Medicare data provides the opportunity to study changes in health status, health care utilization and expenditures in the elderly and disabled U.S. population.

  • Senn says:

    Delivery of clinical preventive services to older adults can reduce premature morbidity and mortality while preserving function and enhancing overall quality of life (1,2).

    Until recently, the use of such services has been low among older adults because Medicare coverage has not been extended to many preventive services (3). Medicare coverage now includes four clinical preventive services: a single lifetime pneumococcal polysaccharide vaccination (vaccine plus any required revaccination and administration) (since 1981); annual influenza vaccination (vaccine and administration) (since 1993); and for women, biennial mammography screening (since 1991) and Papanicolaou smear screening every 36 months (since 1990) (4,5).

    To assess current state-specific levels of use of these services among Medicare beneficiaries, CDC and the Health Care Financing Administration (HCFA) analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the findings of this analysis, which indicate that, despite Medicare coverage of these preventive services, many U.S. adults aged greater than or equal to 65 years did not receive such services in 1995, and state-specific use of these services varied substantially.

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