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Lesson 11: Medicare Appeals

Medicare Appeals

Your Medicare Appeal Rights
You have the right to appeal any decision about your Medicare services. This is true whether you are in the Traditional (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 Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why the 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 the plan`s membership materials or contact the plan for details about your Medicare appeal rights.

Three Tips for Appealing a Medicare Denial:

  • You do not need a lawyer for your appeal. Most appeals are straightforward enough to do yourself or with the help of a friend or family member, especially if you have a letter from your doctor supporting your need for care.
  • File quickly. There are deadlines.
  • Keep copies of all documents and send your appeal certified mail with "Return Receipt Requested."
You are Protected When You are in the Hospital
This is true whether you are in the Traditional Medicare Plan or a Medicare Managed Care Plan.

Assistance with Appeal of a Medicare Denial
Go to www.medicare.gov to obtain the forms to file a Medicare appeal.

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Ohio Senior Health Insurance Information Program (OSHIIP)

50 W. Town St.
Columbus , OH  43215
http://www.insurance.ohio.gov/Consumer/Pages/ConsumerTab2.aspx
oshiipmail@insurance.ohio.gov
Phone: 614-644-2658
Phone Extension: N/A
Area(s) Served: Statewide Contracted Provider: Not Applicable
Description:   Ohio Senior Health Insurance Information Program (OSHIIP)   OSHIIP provides free health insurance information and services for Ohioans with Medicare. They will answer your questions about any of the matters listed below.   Me... read more
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Pro Seniors

7162 Reading Road
Cincinnati , OH  45237
http://www.proseniors.org
Info@proseniors.org
Phone: 513-345-4160
Phone Extension:
Area(s) Served: Butler County,
Warren County,
Clermont County,
Statewide,
Clinton County,
Hamilton County
Contracted Provider: Title III Services
Description:   Pro Seniors is a contracted provider of Council on Aging offering the following services:  legal assistance ombudsman services More about Pro Seniors Founded in 1975, Pro Seniors is a non-profit organization that provides free le... read more

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