If your plan won’t pay for, or doesn’t allow a service that you think should be covered, you can file an appeal. If you have Medicare, you have certain guaranteed rights. One of these is the right to a fair process to appeal decisions about health care payment of services. An appeal is a kind of complaint you make if any of the following applies:
- Your plan refuses to pay for a service, item, or prescription drug that you got and think should be covered.
- Your plan has told you in advance that it won’t cover a service, item, or prescription drug you think should be covered.
- You disagree with the amount that you have to pay for a service, item, or prescription drug you got.
If you decide to file an appeal, ask your doctor, health care provider, or supplier for any information that may help your case. If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. If the plan or physician agrees, the plan must make a decision within 72 hours.
The plan must tell you, in writing, how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. Contact your plan for details about your Medicare appeal rights.
If you believe you are being discharged from a hospital too soon, you have a right to an immediate review by the Quality Improvement Organization (QIO) in your area. A QIO is a group of doctors and health professionals who monitor and review your complaints about quality of care. You will be able to stay in the hospital while they review your case. The hospital can’t force you to leave before the QIO reaches a decision.
In addition, you will have the right to a fast-track appeals process when you disagree with a decision that you no longer need services you are getting from a skilled nursing facility, home health agency, or a comprehensive outpatient rehabilitation facility. You will get a notice from your provider that will tell you how to ask for an appeal if you believe that your services are ending too soon. You will be able to obtain a quick review of this decision, with independent doctors looking at your case and deciding if your services need to continue.
