File A Complaint: Grievance or an Appeal if You Are in a Medicare HMO

If you are on Medicare and enroll in a managed care organization, your MCO must provide all the services you are entitled to under Medicare. Medicare, under Federal law, requires MCOs to follow defined grievance and appeal procedures that differ from grievance and appeal procedures in other types of MCOs.

Medicare Grievances:

If you are questioning a MCO denial of health care you need or payment for health care you’ve received, you should always file an appeal. You can file a grievance for other kinds of complaints or problems with your MCO. Grievances can be about anything other than a denial of health care or payment for services. For example, if you think you had to wait too long to get an appointment with a provider or if you feel you were treated badly by a provider you should file a grievance. Each MCO sets its own procedures for handling your grievance. Read your member handbook to find out your MCO’s procedures. Grievances are not reviewed by any agency outside the
MCO, so it’s important to file an appeal if you need medical coverage.

Medicare Appeals:

Medicare has both standard and expedited appeal procedures. The expedited procedures will allow you, in some cases, to get a decision quickly.

In both expedited and standard procedures, your appeal is reviewed first byby the MCO. After your appeal has been reviewed internally by your MCO, if you still don’t get everything you asked for, your appeal will automatically be reviewed by the Center for Health Dispute Resolution (CHDR). CHDR is a private company that contracts with Medicare to review all MCO appeals.

Here are the Medicare rules for resolving appeals:

When your appeal is about your MCO denying any type of Medicare or HMO-covered benefit or service, or for payment of a Medicare covered service, whether you received the care within or outside your MCO because your MCO refused to provide it, the appeal can be resolved through the following two processes:

Expedited Medicare review:

You can get a quick MCO decision about a MCO denial of care within 72 hours if your health or ability to function at a maximum level could be seriously harmed by waiting for a standard decision.

Ask your doctor to request or support your expedited decision. Your doctor can do this by telephone. If your doctor makes the request or supports your request, the MCO must expedite the decision.

You or your representative can also make the request for an expedited review in writing or orally over the telephone, without support from your doctor or other HCP. In this situation the MCO will
decide whether your condition calls for an expedited decision. If the MCO decides not to expedite your case, the MCO must notify you and give you a written explanation of the reasons for its
decision. Your case will then be decided in the standard time frame. You can file a Medicare grievance about the denial of an expedited appeal, but don’t forget that it is an internal MCO procedure.

If the MCO expedites your review, it must inform you of its decision by phone within 72 hours of receiving the request. Within two working days of making their decision, the MCO must follow-up the phone call with a letter.

If the request for an expedited decision is from a HCP who is not in the MCO’s network, then the 72 hour rule begins after the HCP has supplied all the medical information necessary for the MCO to make a decision. The MCO has to let you know within 72 hours of the request if the HCP has not supplied the needed information.

The 72 hour deadline for making a decision can be extended for 10 working days in the following cases:

When a delay would benefit you. (for example, for more tests or a consultation).
If you request a delay (for example, to gather information).

If the MCO denies the requested care, the MCO must automatically forward your case within 24 hours of making the decision to CHDR. CHDR will then make an expedited decision in the same time frames described above.

As with standard Medicare appeals, if CHDR agrees with your MCO to deny the requested care, you are entitled to an ALJ hearing. ALJ hearings can take a year to schedule, making them less useful in situations where you need care quickly.

Standard Medicare review:

If you do not qualify for an expedited Medicare review, you may use the regular Medicare review process, as follows:

You must first appeal the decision through the MCO’s appeals procedures. If you are appealing a denial of care, the MCO must make a decision within 30 days; if you are appealing a denial of payment for care already received, the HMO must make a decision within 60 days. Then, if
your MCO still denies the benefit, referral or payment, the MCO must automatically forward your complaint or disagreement to the CHDR.

CHDR will review the MCO’s decision and issue a ruling within the same time frames listed above. If CHDR agrees with your MCO to deny the health care or payment for the care, you can appeal further by requesting an Administrative Law Judge Hearing (ALJ). You must request a hearing within 60 days after you receive the CHDR decision. Usually, you must appear in person for
this hearing. ALJs often take 1 year to schedule.

Medicare rules take precedence over New York State law.

For people on Medicare, please remember, once you join an MCO, you can no longer get your
health care through fee-for-service Medicare. For the time being, you can dis enroll (drop out
of any Medicare MCO at any time and return to fee-for-service Medicare.