|
When you are in a Medicare Advantage plan, you have the right
to complain or disagree with your plan.
All Medicare Advantage plans must have grievance and appeal
procedures in place for you to use if you are unhappy with
something the plan did or refused to do. It is important
for you to know the difference between a grievance and an
appeal.
Appeal:
you may file an appeal if payment has been denied for services
that you already received, or if you tried to get prior
authorization to receive a service and were denied. You
may also appeal if you disagree with the amount that you must
pay.
For example:
if your Medicare Advantage plan is refusing to allow or pay
for a cataract surgery, you may appeal this denial.
Grievance:
if you are dissatisfied with the care or services that you
received from your plan or some other aspect of the plan, you
may file a grievance.
For example:
if you had to wait a long time for an appointment with your
primary care doctor or had to wait a long time in the waiting
room, you may file a grievance. The Medicare Advantage
plan must provide all denials of services or payment in writing.
This denial notice must provide an explanation of your
rights to submit an appeal or grievance.
Appeals
You must file an appeal within 60 days of receiving the written
denial, although you can file an appeal as quickly as you choose.
There are presently no time limits for filing a grievance.
If you file an appeal or grievance, your plan must
respond in a timely manner. The amount of time it takes
to resolve your appeal may depend on your medical needs and
whether you have already received the service. Your plan
must have a faster appeal process for situations where your life
or health may be in serious jeopardy.
The first step in an appeal takes place after you receive a
written notice as to whether the plan will allow or pay for a
service. After you have received this notice, you can
request, in writing, that the plan review its negative decision.
This step is called a reconsideration. You must request
reconsideration within 60 days of the written notice.
Then the plan has 60 days to make a decision. However,
you or a physician can request an "expedited" decision, either
orally or in writing. Where a physician requests this,
the plan must make a decision within, generally, 72 hours.
A physician does not have to be part of the plan's network to request an
expedited decision on your behalf. Where you (not a physician) request
the expedited decision, the plan must decide your appeal within 72 hours
if the plan determines that your life or health may be in serious
jeopardy.
If the plan continues to deny payment or services, it must
automatically send its decision to an independent agency, called
the Center for Health Care Dispute Resolution (CHDR).
CHDR then reviews your case and decides whether the plan's denial was correct.
CHDR must send you its decision in writing. If CHDR upholds the
plan's decision and the amount at stake is $100 or more, you
can request a hearing before an Administrative Law Judge.
To request a hearing before an Administrative Law Judge, you must
submit a request for hearing to your local Social Security
Administration within 60 days of receiving the CHDR decision.
A hearing will be scheduled and you will have the opportunity to
speak with an Administrative Law Judge and explain your case.
You will receive a written decision from the Judge. If
you are still dissatisfied and the amount at stake is $1,000 or
more, you may go to Federal Court for judicial review. Again, you
must do this within 60 days of receiving the ALJ decision.
Grievances
The plan may set up its own procedure for filing a grievance.
The plan must tell you how to go about filing a grievance.
While the specific procedures for filing grievances and appeals
will vary between plans, all Medicare Advantage plans must
include the procedures described above. Remember, you
are entitled to disagree with your plan but you must file an
appeal within 60 days of the denial.
A plan may encourage you to try to resolve problems informally
by meeting with the plan's representatives. This could
work for you, but remember that you also have the absolute right
to go through formal procedures, and remember that there are time
limits for those procedures! If in doubt, file an appeal
and try to work it out afterward. Remember also that you have
the right to have a representative help you on your appeal.
This could be an attorney, a benefit specialist or a
friend or relative. SeniorLAW might be able to represent
you free of charge if your case has merit!
|
