Medicare Advantage Appeals and Grievances
You have the right to a fair, efficient, and timely process for resolving issues related to your health plan's payment of a service or product. A Medicare Advantage plan decision regarding the type of service and the amount to reimburse for the service is known as an organization determination. Medicare Advantage plans are required to respond in a timely manner to appeals of organization determinations. Medicare Advantage plans are also required to provide you with written information on how to file an appeal.
If you are unhappy with an organization determination, you must first file a request for reconsideration with the Medicare Advantage plan. Your plan must tell you in writing how to appeal a plan decision. You have the right to 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. After you file an appeal, the plan will review its decision.
The plan must issue its decision on your request within 60 calendar days. If waiting for a decision will harm your health, you may ask for an expedited decision. The plan must answer you within 72 hours.
Is you are still unhappy with the decision, you may then appeal to an independent reviewer. The timeframes are the same as those described above.
Additional reviews are conducted by an administrative law judge and also by the U.S. Department of Health and Human Service's appeals counsel. Finally, you may appeal the decision in federal court.
If the organization determination affects coverage of a continuing inpatient hospital stay, it may be immediately appealed to a Medicare peer review organization. You are not responsible for any costs incurred while this decision is pending.
For more information see your plan's member materials or call your plan for details about your appeal rights and how to file an appeal.
Grievances are complaints you have which do not relate to payment or coverage of benefits. Grievances can include staff attitude, cleanliness of facilities, and waiting times to schedule an appointment. Medicare-contracting HMOs are required to have procedures to handle grievances.
If you are unhappy with a plan decision to not expedite an appeal or with the way you have been treated by plan providers, you should file a grievance with your Medicare Advantage plan. Grievances are separate and different from appeals. Plans are required to explain their grievance process to you and to respond to your grievance in a timely fashion.
Keep in mind that some complaints, which seem to be handled by the grievance procedure, may also be subject to the appeal procedures. For example, long waiting times may also be a denial of care and individuals who face this should file an appeal not a grievance. When in doubt, use the appeal procedures. There are specific time frames for the plan to respond. The case is eventually heard by an impartial organization not affiliated with the HMO.