An appeal is the procedure you follow if you disagree with a decision about your health care. It is a way to deal with a complaint about a treatment decision or service that is not covered. It is different than a grievance, which is a complaint regarding the way your Medicare health plan provides care. For example, you may file a grievance if you have problems with the cleanliness of a facility, reaching the plan’s customer service department, staff behavior or operating hours.
You have the right to appeal any decision regarding your Medicare services. If Medicare does not pay for an item or service, or you do not receive an item or service you think you should, you can appeal. Ask your doctor or provider for a letter of support or related medical records that might help strengthen your case.
You may appoint someone else — a family member, friend, caregiver or doctor — to be your representative in an appeal or complaint.
This section outlines the process for Original fee-for-service Medicare appeals. If a Part A or Part B claim is denied or not handled the way you think it should be, you can appeal the decision. You may request a formal Redetermination of the initial decision. Very few people do this, but more than half of appealed claims result in paid claims or higher payments.
Your rights to appeal are described on the back of the Medicare Summary Notice (MSN) you receive from Medicare each quarter. Previously known as the Explanation of Medicare Benefits, the MSN summarizes:
- Treatment(s) you received during the quarter
- Amounts your providers charged
- Amounts Medicare paid
- Amounts you owe (if any)
In this section, we’ve compiled information on the steps to take for both coverage and payment appeals, and expedited appeals, as well as how to file quality of care complaints.