Section 6: Appeals & Grievances
Your Medicare rights
If you have Medicare, you have certain guaranteed rights to help protect you. One of these is the right to a process for appealing decisions about health care payment or services. Whether you have Original Medicare or a Medicare Advantage Plan (like an HMO or PPO), you have the right to appeal, and to file grievances.
Appeals
An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Health Plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies:
■ Your request for a health care service, supply, or drug that you think you should be able to get
■ Your request for payment for health care services or supplies or a prescription drug you already got
■ Your request to change the amount you must pay for a prescription drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.
Appeal rights in Original Medicare
If you have Original Medicare, you can file an appeal if you aren’t satisfied with a coverage or payment decision. 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 Medicare Summary Notice (MSN) that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why Medicare didn’t pay your bill and how you can appeal. Please review your Medicare notices carefully and follow the instructions before filing an appeal.
Appeal rights in a Medicare health plan
If you’re in a Medicare health plan, or a Medicare Prescription Drug Plan, you can file an appeal for any of the reasons listed here. For more information on your appeal rights, see your plan’s membership materials, contact your plan, or visit www.medicare.gov/publications to view the booklet, “Medicare Appeals.” You may also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Filing a grievance (complaint)
A grievance is different from an appeal. A grievance is for problems you have with the way you get services. If you have a problem with your ESRD dialysis facility:
■ Talk with your doctor, nurse, or facility administrator first to see if they can help you solve your problem. Most problems can be handled at your facility.
■ File a grievance (a written complaint) with your facility if talking to your health care team doesn’t solve the problem.
Every facility has a grievance policy for accepting and trying to work out your problems or concerns. If you don’t know your facility’s grievance policy, ask for a copy of it.
If you filed a grievance with your facility and you still feel that your problem has not been solved, you have the right to file a grievance with the ESRD Network in your area.
More info. Call the ESRD Network to find out how to file a grievance. You can also call your State Survey Agency to complain about your care. Your calls and name will be kept private. Visit www.medicare.gov/contacts to get the phone number to the State Survey Agency. You can also call 1-800-MEDICARE.