Your clients may come to you for help if they are dissatisfied with their healthcare coverage. Depending on the type of problem they are facing, they may want to file a Medicare appeal or grievance. Use the information below to help them navigate these processes, which apply to Original Medicare, Medicare Advantage, and Part D plans.
When to File an Appeal
Clients should use an appeal if they disagree with a coverage or payment decision, such as a claim denial. They can file an appeal if their plan:
- Refuses to cover a service, supply, or medication that they believe it should cover
- Denies a claim for a service, supply, or medication they have already received
- Changes the amount they must pay for a service, supply, or medication
- Stops paying for all or part of a service, supply, or medication they still need
Clients with Original Medicare will find instructions for filing an appeal on their Medicare Summary Notice (MSN). For Medicare Advantage and PDP plans, instructions are on the clients’ Explanation of Benefits (EOB). The MSN and EOB will also include important deadlines for filing the appeal. Beneficiaries should call their plan directly if they need assistance.
There are five levels of appeals. If an appeal is denied, clients can move to the next level. Their denial letter will include instructions on how to move to the next level, along with important timelines. If they feel that waiting for a decision could jeopardize their health, they can file an urgent appeal, which will be expedited.
When to File a Grievance
A grievance is a complaint or expression of dissatisfaction. Appropriate issues for grievances include:
Quality of care issues
- Trouble getting appointments with specialists
- Long waiting times
- Rude or inappropriate behavior by physicians or staff
- Receiving inappropriate surgery or treatment
- Being discharged from a facility too soon or being discharged without proper instructions
Complaints about a plan
- Poor customer service
- Administrative issues, such as taking too long to process an appeal
Complaints about durable medical equipment
- Supplier refuses to fix equipment in a timely manner
- Supplier fails to provide the right equipment
Clients must file grievances within 60 days of the event, and the plan must respond within 30 days.
Clients with Original Medicare should file grievances by calling 1-800-MEDICARE (1-800-633-4227) or by submitting a Medicare Complaint Form. Clients with an MA or PDP plan can file a grievance over the phone by calling the customer service department or by submitting the grievance in writing to their plan’s Grievance and Appeals Department.
How You Can Help
If your clients contact you regarding a denied claim, suggest that they first reach out to the provider and insurer to verify that the claim was submitted and processed correctly. Errors do occur, meaning it may be possible to rectify the issue through an adjustment. If clients do want to proceed with an appeal or grievance, you should help them locate the correct phone numbers, forms, and addresses, if they need this.
Encourage your clients to confirm their benefits, out-of-pocket costs, and any special requirements like prior authorizations before they receive any services. This will avoid unexpected costs and claim denials.
Remind your clients to keep all important documents (including medical bills and receipts) and to document any phone calls, making note of the date and time and who they spoke with. They may need this information to support their grievance or appeal. Remind them that their doctors can also provide supporting medical records, if necessary.
You serve as an important liaison between your clients and their insurers. Your ability to to help them navigate Medicare’s appeals and grievance process reinforces your role as a trusted advisor and demonstrates the value you provide throughout the year.
The dedicated team at Western Asset Protection is here to support you. We are committed to your success. Contact us today.