Coverage Decisions, Appeals and Grievances

How to ask for medical coverage or request an appeal for a service

If you have a Medicare Advantage plan and you’re requesting a medical service, you’ll ask for a coverage decision (organization determination). 

During your inpatient hospital stay you’ll get a notice called “An Important Message from Medicare about Your Rights”. You’ll have to sign it to show that you understand your rights as a hospital patient, including:

• Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them and where you can get them.
• Your right to be involved in any decisions about your hospital stay, and know who will pay for it.
• Where to report any concerns you have about quality of your hospital care. 
• Your right to appeal your discharge decision if you think you're being discharged from the hospital too soon.  

You have the right to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you’re getting:

• Home health care
• Skilled nursing care as a patient in a skilled nursing facility
• Rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). (Usually, this means you’re getting treatment for an illness or accident, or you're recovering from a major operation.)

You’ll receive a "Notice of Medicare Non-Coverage (NOMNC)" in writing at least 2 days before we decide it’s time to stop covering your care. When your coverage for that care ends, we'll stop paying our share of the cost for your care. You can ask to change this decision so you're able to continue coverage.  

Level 1 Appeal

You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.

If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead.

When you'll hear back

Within 48 hours the reviewers will tell you their decision.

Level 2 Appeal

You may ask for this review immediately, but must ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal. 

When you'll hear back

The Quality Improvement Organization will respond to you as soon as possible, but no later than 14 days after receiving your request for a second review.

If you have a complaint about the quality of care or any other services you received through your Medicare plan, you may file a grievance. A grievance is the Medicare term for a formal complaint.

Call us. Select your plan below to find the right phone number.

Other ways to file a complaint

• Submit your complaint online
• Fax or mail us your signed complaint using the contact information shown on the form below.Print our complaint form

• To send a complaint to Medicare, complete the Medicare Electronic Complaint form.

You will receive a response within 30 days.

Helpful Information

• If you have questions about the status of your request or complaint, call us at 1-800-282-5366 (TTY: 711), ${hours}.
  

• If you'd like to get a total for the number of appeals, grievances and exceptions filed with ${company} Medicare, call us at 1-800-282-5366 (TTY: 711). Calls are answered ${hours}.