Whether you have Original Medicare, Medicare Advantage, or a Part D stand-alone prescription drug plan, you have rights and protections through Medicare’s appeal and grievance process.
Filing an Appeal
If you disagree with a decision by your insurer to deny payment, you have the right to file an appeal. Reasons for an appeal include:
- Your plan refused to cover a service, supply, or prescription you think should be covered.
- Your plan denied a claim for a service, supply, or prescription you already received.
- Your plan changed the amount you must pay for a service, supply, or prescription.
- Your plan stopped paying for all or part of a service, supply, or prescription you think you still need.
If you have Original Medicare, directions for filing an appeal can be found on your Medicare Summary Notice (MSN). If you have a Medicare Advantage or Part D drug plan, your Explanation of Benefits (EOB) will provide instructions on how to file an appeal. Both the MSN and EOB will include a deadline date for filing an appeal. If you miss the deadline you can ask for an extension, but you need a good reason such as a serious illness, accident, or a death in the family.
There are five levels of appeals. If you do not agree with the decision made you can move to the next level. You must carefully follow the deadlines and instructions in your decision letter. If you feel that waiting for a standard appeals decision could put your health at risk, you can request an urgent appeal. You can get help filing an appeal from your doctor, attorney, family member or other advocate.
Filing a Grievance
A grievance, also known as a complaint, allows you to express dissatisfaction with the quality of care or services that you received. Examples include complaints about inappropriate or rude behavior of a provider or their staff, trouble getting appointments, or complaints about durable medical equipment. You can also file a complaint about how you are being treated by your plan, such as poor customer service or a delay on deciding an appeal.
If you have Original Medicare you can file a complaint by calling 1-800-MEDICARE (1-800-633-4227) or by submitting a Medicare Complaint Form. If you have a Medicare Advantage or Part D plan you can send a written complaint to your plan’s Grievance and Appeals Department or you can call the customer service phone number on your ID card and request to file a grievance over the phone.
You must file your grievance within 60 days of the event that led to the complaint. You should be notified of the results of the plan’s investigation within 30 days.
Other Steps You Can Take
- If you receive a denied claim, check with your provider and your insurance plan to confirm that the claim was submitted and processed correctly. It’s possible someone made an error that can be easily rectified.
- Make sure you understand your benefits. If you are uncertain about your coverage for a specific service check with your provider or insurer to see how it will be covered. Ask what your out of pocket costs will be and if preauthorization is required. This will help you avoid any surprises such as denied claims.
- Thoroughly review provider bills and compare them to your MSN’s or EOB’s. This will help you identify any discrepancies. Keep copies of all important documents including medical bills and payment receipts. Document the dates and times of any phone calls along with who you spoke to. You may need this information to support a grievance or appeal.
If you need guidance on navigating Medicare’s grievance and appeals process, the team at Healthcare Educators is here to help. Contact us today.