How to file Medicare appeals, deal with issues, claims, problems, etc.
If you have questions, you’re welcome to post anonymously at the bottom of this page or the most relevant page on our website and we will research and answer it. We don’t get paid to help you with appeals or grievances. We will assist our clients.
How to file a complaint – Medicare.Gov
Medicare Appeals Publication # 11525 60 pages
HICAP CA * Rest of USA * (Health Insurance Counseling and Advocacy Program) provides free, confidential one-on-one counseling, education, and assistance to individuals and their families on Medicare, Long-Term Care insurance, other health insurance related issues, and planning ahead for Long-Term Care needs. HICAP also provides legal assistance or legal referrals in dealing with Medicare or Long-Term Care insurance related issues.
HICAP counselors are trained in Medi-Cal and Medicare and can help you understand the complex insurance options to find the best fit for you. You can also learn about Medicare or Medi-Cal by attending community presentations or conferences conducted by HICAP counselors. Medicare & You – see link in side panel
***Sure they might be of help, but how much training, licensing, malpractice coverage and experience do licensed agents have.
Look at all the information on this site!
- This is NOT sales literature, but is provided as a public service for educational purposes.
- AARP Procedures on problems, complaints & appeals from EOC
See our general section on Appeals & Grievances
With all your experience, is there any effective [grievance] agency for me to go to with the HMO Medicare advantage plan [UHC – AARP] I have? One of UCLA, Endocrinologists made a huge medication error, from which I am very ill. UCLA has denied me a second opinion or a higher level of care.
***One of the very best places to view your rights and procedures for claim problems, appeals, grievances is in the full EOC – Evidence of Coverage that you have a right to view before purchasing or when you get it in the enrollment paperwork or shortly thereafter. Get your EOC go to Table of Contents – Then look for Appeals, claims procedures, etc. and of course the explanation of benefits and if your issue is actually covered.
Sibling & Child Pages
Our general section on Appeals & Grievances
Medicare Appeals # 11525
This official government booklet has important information about:
■ How to file an appeal if you have Original Medicare
■ How to file an appeal if you have a Medicare Advantage Plan or other Medicare health plan
■ How to file an appeal if you have Medicare prescription drug coverage
■ Where to get help with your questions
Filing an appeal with Medicare
How to Appeal a Denial of your Health Claim - Kantor & Kantor Attorneys
Technical & Research Links
One hour webinar by an attorney, on how to do claims & appeals – You Tube
42 CFR Part 422, Subpart M – Grievances, Organization Determinations and Appeals
- § 422.560 — Basis and scope.
- § 422.561 — Definitions.
- § 422.562 — General provisions.
- § 422.564 — Grievance procedures.
- § 422.566 — Organization determinations.
- § 422.568 — Standard timeframes and notice requirements for organization determinations.
- § 422.570 — Expediting certain organization determinations.
- § 422.572 — Timeframes and notice requirements for expedited organization determinations.
- § 422.574 — Parties to the organization determination.
- § 422.576 — Effect of an organization determination.
- § 422.578 — Right to a reconsideration.
- § 422.580 — Reconsideration defined.
- § 422.582 — Request for a standard reconsideration.
- § 422.584 — Expediting certain reconsiderations.
- § 422.586 — Opportunity to submit evidence.
- § 422.590 — Timeframes and responsibility for reconsiderations.
- § 422.592 — Reconsideration by an independent entity.
- § 422.594 — Notice of reconsidered determination by the independent entity.
- § 422.596 — Effect of a reconsidered determination.
- § 422.600 — Right to a hearing.
- § 422.602 — Request for an ALJ hearing.
- § 422.608 — Medicare Appeals Council (MAC) review.
- § 422.612 — Judicial review.
- § 422.616 — Reopening and revising determinations and decisions.
- § 422.618 — How an MA organization must effectuate standard reconsidered determinations or decisions.
- § 422.619 — How an MA organization must effectuate expedited reconsidered determinations.
- § 422.620 — Notifying enrollees of hospital discharge appeal rights.
- § 422.622 — Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
- § 422.624 — Notifying enrollees of termination of provider services.
- § 422.626 — Fast-track appeals of service terminations to independent review entities (IREs).