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Medicare Appeals
Medicare Appeals
Your Medicare Appeal Rights
You have the right to appeal any decision about your Medicare services. This is true whether you are in the Traditional (Original) Medicare Plan or a Medicare Managed Care Plan. If Medicare does not pay for an item or service you have been given, or if you are not given an item or service you think you should get, you can appeal.
Appeal Rights Under the Original Medicare Plan
If you are enrolled in the Original Medicare Plan, you can file an appeal if you think Medicare should have paid for, or did not pay enough for, an item or service you received. If you file an appeal, ask your doctor or provider for any information related to the bill that might help your case. Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. The notice will also tell you why the bill was not paid and what appeal steps you can take.
Appeal Rights Under Medicare Managed Care Plans
If you are in a Medicare Managed Care Plan, you can file an appeal if your plan will not pay for, does not allow, or stops a service that you think should be covered or provided. If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. The plan must answer you within 72 hours. The Medicare Managed Care Plan must tell you in writing how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan does not decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. See the plan`s membership materials or contact the plan for details about your Medicare appeal rights.
Three Tips for Appealing a Medicare Denial:
- You do not need a lawyer for your appeal. Most appeals are straightforward enough to do yourself or with the help of a friend or family member, especially if you have a letter from your doctor supporting your need for care.
- File quickly. There are deadlines.
- Keep copies of all documents and send your appeal certified mail with "Return Receipt Requested."
You are Protected When You are in the Hospital
This is true whether you are in the Traditional Medicare Plan or a Medicare Managed Care Plan.
Assistance with Appeal of a Medicare Denial
Go to www.medicare.gov to obtain the forms to file a Medicare appeal.
Ohio Senior Health Insurance Information Program (OSHIIP)
Columbus OH 43215
Description:
Ohio Senior Health Insurance Information Program (OSHIIP)
OSHIIP provides free health insurance information and services for Ohioans with Medicare. They will answer your questions about any of the matters listed below.
- Medicare health coverage for seniors and for people under age 65 with disabilities
- Medicare prescription drug plans
- Medicare Advantage Plans (example: HMOs and PPOs)
- Medicare supplemental insurance
- Financial assistance programs for people with limited income
- Long-term care insurance
- Home health care coverage
- Retiree health plan coverage
Toll-free Hotline
OSHIIP's Medicare experts speak with hundreds of callers daily. They provide objective, accurate information and assistance. Call toll-free from anyplace in the USA: 1-800-686-1578
Local volunteer counselors
OSHIIP is involved in your neighborhood.
- OSHIIP has trained and certified more than 800 volunteers across the state
- Volunteer counselors are experts on Medicare and related health insurance matters
- A local volunteer can meet with you in person or speak with you over the telephone
Want to become an OSHIIP volunteer?
Without volunteers, OSHIIP could not fulfill its mission. Dedicated people are needed to be volunteers in all parts of Ohio. As a volunteer, you will:
- Learn about Medicare in a free 22-hour course
- Help people in your community
- Have the satisfaction of taking part in a truly worthy cause
For more information, contact OSHIIP about the next training course in your area. Call 1-888-686-VOLS or email oshiipmail@insurance.ohio.gov.
Pro Seniors
Cincinnati OH 45237
Description:
Pro Seniors is a contracted provider of Council on Aging offering the following services:
- legal assistance
- ombudsman services
More about Pro Seniors
Founded in 1975, Pro Seniors is a non-profit organization that provides free legal and long-term care help to older adults. Pro Seniors offers Ohio residents age 60 and older the advice and information they need to solve their legal and nursing home, adult care facility, and home health care problems.
The Pro Seniors Mission
Pro Seniors is dedicated to helping older adults maintain their independence by empowering them, by protecting their interests, and by helping them access resources.
What Pro Seniors Offers
Pro Seniors Legal Hotline serves the State of Ohio. By calling the Pro Seniors Legal Hotline, Ohio residents age 60 or older can receive free assistance over the telephone with a variety of legal or long-term care problems. In Greater Cincinnati, the number to call is (513) 345-4160. In other parts of Ohio, call (800) 488-6070. Find more information on the Legal Hotline by selecting the Legal Hotline link.
Legal Help
If you have a legal problem that cannot be resolved over the telephone, the Legal Hotline may refer you to a Pro Seniors staff attorney if you live in Butler, Clermont, Clinton, Hamilton or Warren County. Pro Seniors' staff attorneys handle problems that many private attorneys do not, such as Medicare, Medicaid, Social Security, other government benefits and pensions. The Legal Hotline may also refer you to a private attorney who has agreed to accept cases at a reduced fee for clients with limited income.
Legal Information Pamphlets
Pro Seniors provides pamphlets on a variety of subjects, from Medicare and Medicaid to consumer fraud and food stamps. You can find a complete list by selecting the Pamphlets link.
Long-term Care Ombudsmen
If you have a complaint about a nursing home, Pro Seniors can help. The long-term care ombudsmen will investigate and work with you to resolve your concerns about nursing facilities in Butler, Clermont, Clinton, Hamilton, and Warren counties. Pro Seniors ombudsmen also handle complaints about home care and adult care facilities. You can find more information about the Ombudsman program by selecting the Ombudsman link. The Ombudsman can also help you choose the right care facility to meet your needs.
Volunteer Opportunities
If you are interested in assisting older people and have a few free hours each week, Pro Seniors offers a variety of volunteer opportunities. For more information about our volunteer Ombudsman Program, select the Ombudsman link. If you are concerned about fraud and waste in the health care system, select the Ohio Seniors Fight Fraud link to learn more about volunteering for this project. If you are an attorney, you can assist callers to the Legal Hotline or conduct legal research. Paralegals can provide valuable support to our legal staff. Volunteers also are needed to assist staff with mailings and other office projects.