Council on Aging Answers 2016 - 92

Know Your Medicare Rights

INSURANCE

COUNCIL ON AGING - ORANGE COUNTY

Medicare beneficiaries have the right to appeal
any coverage or payment decision made by
Medicare, a Medicare health plan, or a Medicare
Prescription Drug plan.
All Medicare beneficiaries receive either a
Medicare Summary Notice (MSN) or Explanation
of Benefits (EOB), depending on whether you
are enrolled in Original Medicare or a Medicare
health plan. The MSN or EOB lists all services and
items billed to Medicare or your plan, and whether
Medicare (or a plan) paid in full, partially paid, or
did not pay for a service or item.
Do NOT Ignore the Label: "This Is Not a Bill"
on MSN or EOB
Medicare beneficiaries should always review
each MSN or EOB received, to ensure that the
listed services and items were actually provided to
the beneficiary AND to ensure that Medicare (or
plan) covered the claims. If the "Service Approved"
column shows "NO", then the beneficiary needs to
follow-up with Medicare (or plan) to understand
why the claim was not approved. Do not assume
that the issue will resolve itself. You need to take
appropriate action, such as filing an appeal, or
paying the amount due. An unpaid claim could lead
to your account being turned over to a collection
agency.
If you disagree with the initial coverage decision,
you may appeal. The instructions for filing an appeal
are included on the MSN or EOB. You must explain
why you disagree with the decision, and provide any
documentation, such as a physician's statement, that
supports your position.
If the appeal is denied, and you disagree with the
decision, you may appeal to the next level (there are
five appeal levels). The appeals process is complex, so
beneficiaries may wish to seek assistance from their
local HICAP office.
Challenging Hospital Discharge Decisions
During a hospital stay, Medicare beneficiaries
92

Answers Guide 2016

have important rights to receive the medical care
they need. You have these rights whether you are
enrolled in Original Medicare or a Medicare health
plan.
To protect you from being discharged too quickly,
Medicare gives you the right to appeal hospital
discharge decisions. It also requires the hospital to
provide any discharge planning services you need.
To make sure you are informed about your
discharge rights in a timely manner, hospitals must
give you the "Important Message from Medicare"
twice, once upon admission, and again before
discharge. The hospital must deliver the "Important
Message" to you in person. However, if you cannot
understand the notice, the hospital must deliver it to
your representative and ask him or her to sign it.
Appealing Hospital Discharge Decisions
Your hospital, doctor, or Medicare health plan
will inform you of your planned date of discharge. If
you think you are not ready to leave the hospital, tell
your doctor and the hospital staff immediately about
your concerns. You should request an appeal if your
concerns about early discharge are not resolved.
To file your appeal, call Livanta, the West Coast's
Beneficiary and Family Center Care - Quality
Improvement Organization (BFCC-QIO) at 1-877588-1123, or visit www.BFCCQIOAREA5.com. Tell
them why you object to the planned discharge and
provide any information that supports your appeal.
Medicare Appeal Advocacy
The HICAP program of the Council on Aging -
Orange County assists Medicare beneficiaries who
wish to file an appeal of a decision by Medicare, a
Medicare health plan or a prescription drug plan. A
HICAP specialist will help to prepare an appeal and
advocate for the client at the various levels of appeal.
Call (714) 560-0424 ext. 218 to speak with a HICAP
Appeals Advocate.

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