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Filing an Appeal or Grievance with Medicare

Filing an appeal or grievance is a right that you have regarding your Medicare services. You have these rights under the original Medicare plan, a Medicare managed care plan or a Medicare prescription drug plan. If you submit a claim for which Medicare denies payment you may appeal the decision. If you believe you should get an item or receive a service that you did not receive you may appeal the decision.

Filing an appeal, under the original Medicare plan, requires that your doctor or medical provider provide any and all information regarding the bill. You may review your appeal rights on the back of the Explanation of Medicare Benefits or Medicare Summary Notice. These documents are mailed to you. In addition the notice will tell you why the bill wasn’t paid.

Under a Medicare Managed Care Plan you may file an appeal if your plan won’t pay, doesn’t allow or stops a service you believe should be covered or provided. Your Medicare Managed Plan must provide you with a written explanation of how to appeal. If you or your doctor suspects that a lengthy appeal decision could have a negative affect on your health, you have a right to ask the plan for an expedited decision. Your plan must answer within 72 hours. If after your appeal, your plan does not decide in your favor an independent organization for Medicare, not your plan will review the appeal. For more information regarding appeals and grievances process under a Medicare Managed Care Plan go to http://www.cms.hhs.gov/MMCAG.

If you have a Prescription Drug Plan, you can appeal a plan sponsor’s decision to provide or pay for a Part D prescription drug that you believe should be provided or paid. In this context “provide” means authorizing prescription drugs, paying for prescription drugs or continuation of a Part D prescription drug you’ve been taking. Your Prescription Drug Plan must provide in writing, how to go about an appeal.

When you file a standard appeal under a Prescription Drug Plan your plan sponsor must answer you within seven (7) calendar days of receiving the appeal. Of course if you and/or your doctor believe your health would be jeopardized by waiting seven (7) days you may ask for an expedited decision and the plan must provide a response within 72 hours.

If your Prescription Drug Plan sponsor does not decide in your favor, you may appeal the decision with an independent organization working for Medicare. If you have other concerns or problems with your Prescription Drug Plan sponsor that don’t have to do with providing or paying for a Part D drug, you have the right to file a grievance. An example of a grievance is a complaint about how high the cost sharing amount is but you do not feel it is incorrect. For more information regarding appeals/grievances under prescription drug plan visit http://www.cms.hhs.gov/MedPrescriptDrugApplGriev.

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