Module 1 - Overview of Medicare Program Basics: Choices, Eligibility, and Benefits - APPEALS Flashcards
Appeals Generally:
Beneficiaries receiving their Part A and/or Part B services through Original Medicare have a right to appeal Medicare coverage and payment decisions
What is a Medicare Summary Notice (MSN)?
The Medicare Summary Notice (MSN) shows the Part A and Part B services and supplies that providers and suppliers billed to Medicare on their behalf. Beneficiaries should look at their Medicare Summar Notice (MSN).
The MSN also shows what Medicare paid on the beneficiary’s behalf and what the beneficiary may owe the provider. The MSN also shows if Medicare has fully or partially denied their medical claim.
Beneficiaries can also track their Medicare claims or view electronic MSNs by visiting MyMedicare.gov.
When can a beneficiary file an Appeal?
Beneficiaries must file an appeal related to Part A or Part B services within 120 days of the date the MSN in the mail. The appeal should be sent to the Medicare Administrative Contractor (MAC) that processed their claim (indicated on the MSN). Instructions for filing an appeal can be found on Medicare.gov
What must the beneficiary do if he disagrees with the decision of the Medicare Administrative Contractor (MAC):
If the beneficiary disagrees with the MAC’s decision on the appeal, they have 180 days after getting the decision to request a reconsideration by a Qualified Independent Contractor (QIC).
Additional levels of appeal may be available depending on the amount in controversy.
Fast appeals under Original Medicare for Certain Services:
- Beneficiaries receiving their Part A and/or Part B services through Original Medicare have a right to a fast appeal if they believe certain Medicare-covered services are ending too soon.
- This includes services provided by a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice.
- Their provider will give them written notice before the end of their services. The notice tells them how to ask for a fast appeal.
Grievances under Original Medicare:
Beneficiaries may also file complaints about their Medicare providers or the quality of care they received. For example, a beneficiary may have a complaint about:
- unprofessional conduct by a provider
- improper care
- unsafe conditions
- abuse by a provider
- long waiting times or unclean conditions
Additional Beneficiary Protections under Original Medicare:
Medicare operates a 24-hour helpline at 1-800-Medicare.
Beneficiaries can use this number to find out about their claim status, coverage and benefits, and premium payments, or to ask other questions about Medicare.
Beneficiaries can also get assistance with Medicare, including help filing an appeal or grievance, through their local State Health Insurance Assistance Program (SHIP)
