Medicare Appeals and Grievances

Your Medical Appeal Rights

You have the right to appeal any decision relating to your claims for benefits. 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 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.

Fast Appeals in Hospitals

When you are admitted as an inpatient to a hospital, you have the right to get all the hospital care that is necessary to diagnose and treat your illness or injury. The day you leave the hospital (your discharge date) is based on when your inpatient hospital stay is no longer medically necessary. This section explains what to do if you believe that you are being discharged too soon.

Information you should get during your hospital stay

As part of the pre-admission process (but not more than seven days before admission) or within two days of admission as an inpatient, someone at the hospital must give you a notice called "An Important Message from Medicare About Your Rights" (the "IM"). If you don't get this notice, ask for it. This notice explains the following:

  • Your right to get all medically necessary hospital services
  • Your right to be involved in any decisions that the hospital, your doctor, or anyone else makes about your hospital services and who will pay for them
  • Your right to get services you need after you leave the hospital
  • Your right to appeal a discharge decision and have your hospital services paid for during the appeal (except for any applicable coinsurance or deductibles)
  • Your potential financial liability for continuing to stay in the hospital after your discharge date

You or your representative will be asked to sign the IM. If the hospital gives you the IM more than two days before your discharge day, it must give you a copy of your signed IM before you are discharged.

Review of your hospital discharge by the Quality Improvement Organization

You have the right to ask a Quality Improvement Organization (QIO) to review whether you are being discharged too soon. 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. If you have questions about this, call toll-free 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048.

State Health Insurance Program

You can also call your State Health Insurance Program (SHIP) for help filing an appeal. SHIP is a free counseling service for Medicare beneficiaries that provides information regarding Medicare and Medigap insurance policies.

SHIP's Medigap Helpline (1-800-242-1060) can help you with questions about health insurance, primarily Medicare supplements, long-term care insurance, and other health care plans available to Medicare beneficiaries. The Medigap Helpline is provided by the State of Wisconsin Board on Aging and Long-Term Care at no cost to you. There is no connection with any insurance company.