Appeals


Hospital Appeals

A Medicare beneficiary has the right to appeal a hospital discharge if he or she feels too sick to leave. A Medicare beneficiary can do this even if he or she is in an HMO. The hospital will provide "An Important Message from Medicare," which explains how to appeal the discharge.

Medicare beneficiaries can call HSAG at 1-800-841-1602 for an appeal. HSAG staff members will look at the medical record to see if the beneficiary should stay in the hospital. The beneficiary will be informed of the decision

• The Medicare beneficiary does not have to leave the hospital.
• The Medicare beneficiary does not have to pay for the extra days in the hospital while HSAG staff members
  review the medical record.
• Additional information is available at 1-800-MEDICARE (633-4227).

Other Appeals

A Medicare beneficiary has the right to appeal a discharge if he or she does not agree with the discontinuation of skilled services. The beneficiary must be given a letter with the planned discharge date explaining how to appeal the discharge. A Medicare beneficiary can appeal even if he or she is in an HMO.

Once the beneficiary receives the letter, he or she can call HSAG at 1-800-841-1602. An HSAG physician will look at the medical record to see if the services should continue. The Medicare beneficiary will be informed of the decision. Additional information is available at 1-800-MEDICARE (633-4227).

Managed Care Denial of Coverage

If a Medicare beneficiary is in an HMO, he or she has some additional Medicare rights. If the beneficiary feels he or she cannot get the needed care, he or she has the right to appeal to the HMO. The Medicare beneficiary can appeal things like denials for:

• Referrals to a specialist.
• Approval for tests (like x-rays or blood tests).
• Payment of a bill.

The HMO has information about how to start the appeal process. A Medicare beneficiary who feels he or she may get worse by waiting too long can ask for an expedited appeal. This means the HMO must make a decision about the appeal within three calendar days. A Medicare beneficiary who needs an expedited appeal must be sure to ask for it.  

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