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Your Rights and How to Appeal PDF Print E-mail

Your rights as a hospital patient

Federal law requires hospitals to provide all Medicare patients with a pamphlet, “An Important Message From Medicare.” This pamphlet describes rights and responsibilities and where to go if you have questions.

Your doctor, your plan, or the hospital should arrange for services you will need after you leave the hospital. Medicare or your plan may cover some care in your home (home health care) and other kinds of care, if ordered by your doctor or by your plan. You have a right to know about these services, who will pay for them, and where you can get them. If you have any questions, talk to your doctor or plan, or talk to other hospital personnel.

Keep copies of paperwork you receive and document your calls (names of people you spoke with), letters and dates of contact.

Your hospital discharge and Medicare appeal rights

Date of discharge: When your doctor or plan determines that you can be discharged from the hospital, you will be advised of your planned date of discharge. You may appeal if you think you are being asked to leave the hospital too soon. If you stay in the hospital after your planned date of discharge, it is likely that your charges for additional days in the hospital will not be covered by Medicare or your plan.

Your right to an immediate appeal without financial risk: When you are advised of your planned date of discharge, if you think you are being asked to leave the hospital too soon, you have the right to appeal to your Quality Improvement Organization (QIO). The QIO is authorized by Medicare to provide a medical review of your readiness to leave. You may call Medicare toll-free, 24 hours a day, at 1-800/MEDICARE (1-800/633-4227), or TTY/TTD: 1-877/486-2048, regarding asking your QIO for a medical review. If you request an immediate appeal, the QIO will decide within one working day on your readiness to leave the hospital after it receives the necessary information.

Other hospital appeal rights: If you miss the deadline for filing an immediate appeal, you may still request a review by the QIO (or by your plan, if you are a plan enrollee) before you leave the hospital. However, you will have to pay the costs of your additional days in the hospital if the QIO (or your plan) denies your appeal. You may file for this review at the address or telephone number of the QIO (or your plan).

Appeals involving non-hospital care settings

In addition to hospital appeal rights, Medicare beneficiaries enrolled in traditional Medicare have the right to appeal a decision to discontinue coverage of services provided by home health agencies, skilled nursing facilities, and Comprehensive Outpatient Rehabilitation Facilities (CORFs), as well as hospice services provided in a hospice facility or at home.

If services like these are being discontinued, you or your representative should receive a written notice from the health care provider at least two days before the services are scheduled to end. This notice will tell you when payment for the services will end, and how to appeal by requesting an immediate appeal of your case.

Stratis Health’s toll-free number for these requests is 1-877/624-1414 or TTY/TTD 1-800/627-3529, between 8:30 a.m. and 4:30 p.m., including weekends.

If you request an immediate appeal, Stratis Health will decide within one day of receiving all the necessary information whether services you are receiving are appropriate and eligible for Medicare payment.

If Stratis Health agrees that services are appropriate and eligible for payment, the provider will continue those services until your physician writes an order to discontinue them, or until the provider issues another written notice.

The Medicare beneficiary complaint response program

Beneficiaries not satisfied with the care they have received from a physician or provider can contact the QIO in their state. Stratis Health is the QIO for Minnesota.

Stratis Health reviews complaints regarding quality of care issues in the following Medicare-certified settings: hospital (inpatient and outpatient), skilled nursing facility, ambulatory surgery center, emergency room, home health agency, hospice, managed care organization, doctors’ office, outpatient physical therapy, speech and language pathology services, specialty hospital (psychiatric and rehabilitation) and community mental health facility.

When problems are identified, quality improvement efforts are undertaken. There are now two options for resolving a complaint: Medical Record Review and Mediation. You can call Stratis Health at 1-800/444-3423 with your concern and for an explanation of both options.

Appeals involving an HMO or Medicare supplement

An appeal or complaint against an HMO or Medicare supplement or agent can be filed for various reasons: perhaps denial of payment, referrals were not given, further treatment was not covered, or urgently needed or emergency care payment was denied or misrepresentation by the agent. Depending on the type of Medicare supplement, the appeal/complaint process varies. You may be able to resolve your problem quickly by calling your HMO or insurance company and explaining your complaint. If not, read on.

The most important thing to remember is to keep a paper trail to track your appeal/complaint. Make sure you keep copies of everything you send. Keep track of all phone calls you make. Note the date and time of call, whom you spoke with, what was discussed and the outcome of the call.

Medicare supplements (Basic, Extended Basic, and H, I or J policies)

Contact the provider of your Medicare supplement about your appeal/complaint. If you are not able to resolve it, you can file an appeal or grievance against the supplement company or an individual agent selling a Medicare supplement policy. Contact the Minnesota Department of Commerce Consumer Response Team at 651/296-2488 or toll-free 1-800/657-3602.

Medicare Select and Cost plans

  1. First, contact your Medicare Select health carrier, HMO or Cost plan about your appeal/complaint. The plan must promptly send you a complaint form. Fill out and file the written complaint form with the plan, which must provide you with a written statement of their decision within a reasonable time frame (usually 30-44 days).
  2. If you are not satisfied with the plan’s decision, you have the right to request a reconsideration or hearing. The HMO plan must give you information regarding your rights and how to proceed.
  3. Contact the Minnesota Department of Commerce at 651/296-2488 or 1-800/657-3602 with your complaint and the Minnesota Department of Health at 651/282-5600 or 1-800/657-3916.

Medicare Advantage Plans

  1. First, contact the HMO, health carrier or insurance company to file a reconsideration. The company must issue a decision to you within 60 days. Also contact the Minnesota Department of Commerce at 651/296-2488 or 1-800/657-3602, and the Minnesota Department of Health at 651/282-5600 or 1-800/657-3916.
  2. If the plan denies part or all of your appeal, they must send your case file to The Center for Health Care Dispute Resolution in New York. The Center contracts with Medicare to review all Medicare Advantage appeals and denials.
  3. If the Center does not rule totally in your favor and the amount left in dispute is $100 or more, you can request a hearing before a Social Security Administrative Law Judge (ALJ). You must file a Request for Hearing within 60 days of receiving the Center’s decision.
  4. If you are not satisfied with the ALJ’s decision and there is more than $1,000 in dispute, you can request a Departmental Appeals Board Review.
Because Medicare Advantage is a federal plan, the appeals process takes more time, so be patient if you pursue your appeal.

This article was prepared by Kate Johnston, Stratis Health, and John Gross, Director of Health Care Policy, Minnesota Department of Commerce.
Health Care Choices for Minnesotans on Medicare