Appeals: An Important Right for Medicare Beneficiaries

By Ellen Pothier, MS, RN, CPHQ
Beneficiary Outreach and Mediation Coordinator, Masspro

Sometimes, Medicare beneficiaries feel they have been released from hospital, nursing home, home health agency or hospice care before they are ready to leave. All Medicare beneficiaries, whether covered under Original Medicare or a Medicare Advantage Plan, have appeal rights. This means that trained medical professionals will review the beneficiary’s medical record and decide whether the beneficiary has been released too soon or whether the timing of the release was correct.

Below are some steps to follow if you feel you are being released from a hospital, nursing home, home health agency or hospice too soon:

  1. Talk to your doctor about continuing your care.
  2. Ask your case manager or social worker for an official (written) Medicare notice.
  3. Follow the instructions on the notice. Masspro’s helpline telephone number will be listed on the notice.
  4. For the best protection, and a fast decision, call Masspro right away after receiving the notice.
  5. Masspro will ask you for your views and review your medical record.
  6. You’ll be informed of Masspro’s decision first by phone and then by mail. At that time, you will also receive information about other appeal rights.

You have the right to a fast appeal decision (also called an expedited determination) when you receive a Medicare notice that your services will be ending. For the best protection, and a fast decision, call Masspro right away after receiving the notice.

Call Masspro’s helpline at 1-800-252-5533, or Medicare at 1-800-MEDICARE (1-800-633-4227). You can call or you can ask a friend or family member to call for you.

Note: If you call Masspro’s helpline outside of normal business hours (Monday-Friday, 8:30 am – 5:00 pm) make sure to listen carefully to the after-hours helpline message and follow the instructions to leave a message.