Vol. 14, Issue 4 – February 23, 2015

What is the difference between an appeal and a grievance?

Dear Marci,

My Medicare Advantage plan recently refused to pay for a lab test I received. One friend told me that I should file an appeal with the plan, but another told me that I should file a grievance. What is the difference between an appeal and a grievance?

–  Gary (Santa Barbara, CA)

Dear Gary,

An appeal is a request that you make to Medicare or your Medicare Advantage or stand-alone Part D plan to reconsider its decision to deny coverage of an item, service, or medication. If your Medicare Advantage plan refuses coverage, it must send you a written notice that explains the reason for the denial and your appeal rights.  A grievance is an official complaint filed with your Medicare Advantage or Part D plan if you are dissatisfied with the behavior or actions of your plan or its representatives. A grievance might be filed if your plan has poor customer service, or if it takes too long to process an appeal. In some situations, you may want to file both an appeal and a grievance.

In your circumstance, if your plan refuses to pay for a lab test that you received, then you should file an appeal. The appeal will ask your Medicare Advantage plan to reconsider its decision to deny coverage of the test. If your plan is covering the lab test but you were dissatisfied with the plan’s actions during the process (for example, a plan representative was unhelpful when you asked how to file an appeal), you can file a grievance.

Keep in mind that there are different kinds of Medicare appeals. The appeals processes and timelines differ among these types of appeals. For example, you can request a faster timeline with your Medicare Advantage or Part D plan if your health or life would be jeopardized without the service, item, or drug. Fast appeal timelines are called expedited appeals. Ask your doctor for help filing an expedited appeal. You can also get a fast appeal if your hospital, home health agency, skilled nursing facility, hospice or comprehensive outpatient rehabilitation facility (CORF) care is scheduled to end. Make sure to follow the instructions and stick to the timeframes listed on the denial or termination notices. There are higher levels of appeal if you are unsuccessful at the first level.

To file a grievance, send a letter to your plan’s Grievance and Appeals department. Contact your plan for the address. You can also file a grievance by calling your plan, but it is best to send your complaints in writing. You can also send a grievance to Medicare over the phone, to do this call 800-MEDICARE and ask to file a grievance against a plan. Be sure to send your grievance to your plan within 60 days of the event that led to your grievance. Your plan must investigate your grievance and get back to you within 30 days. If your request is urgent, your plan must get back to you within 24 hours. If you have not heard back from your plan within this time, you can call your plan or 800-MEDICARE to check on the status of your grievance.


Health Tip
The Advisory Committee on Immunization Practices (ACIP), which is the vaccine advisory panel for the U.S. Centers for Disease Control and Prevention (CDC), recently recommended that older adults receive two vaccines to better protect themselves from pneumonia. The committee recommended that adults age 65 and older receive both the Prevnar 13 and Pneumovax 23 vaccines to protect against the pneumococcal bacteria that cause pneumonia. Each vaccine works in a different way, and getting both vaccines offer broader protection. Additional protection is especially important for older adults, who are more vulnerable to serious infections. Medicare Part B will cover the both vaccines as part of preventive care.

To read the full story from MedlinePlus, click here. To read about Medicare’s coverage of pneumonia vaccines, click here.

Need to Know
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