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How to Appeal a Medicare Refusal to Pay

You have rights. Know how to use them.  

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Like any other health coverage plan, Medicare does not pay for all of your health care needs. And, like any other health plan, Medicare sometimes wrongly refuses to pay for things they should cover. When this happens, you do not have to just take it. You have every right to appeal Medicare's decision.

  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 the Original Medicare Plan or a Medicare managed care 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 the Original Medicare Plan:

If you are enrolled in the Original Medicare Plan, 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.

If you have concerns or problems with your plan which are not about payment or service requests, you have a right to file a grievance. For example, if you believe your plan's hours of operation should be different, you can file a grievance.

You are protected when you are in the hospital:

This is true whether you are in the Original Medicare Plan 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 Quailty 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.

    [Source: www.medicare.gov]

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