Your Medicare Appeal Rights
If Medicare Part B has denied payment for your medical claim, or if you have a question on the amount of payment made, you can call 1-800-MEDICARE (1-800-633-4227). Our representatives can explain to you the facts we used to decide what and how much to pay.
If you do not agree with the decision made on your claim, you have the right to a redetermination. In order to be eligible for a redetermination, you must make your request for the redetermination within 120 days of the date of the initial claim determination. If you want help with your redetermination, you can have a friend or someone else help you. Requests for redetermination must be submitted in writing if your claim was processed on or after January 1, 2006.
Telephone redeterminations will only be processed for claims that were processed on or before December 31, 2005, can be easily resolved at the time of the call. Therefore, if you do not agree with the decision made on your claim, please call 1-800-MEDICARE (1-800-633-4227). A representative will be able to assist you in determining if your claim can be reviewed on the Telephone Redeterminations line.
At the time of the call, we will need the following information:
- Name
- Medicare Number
- Date of Service
- Billed Amount
- Reason for the Appeal
Our representatives are available to assist you from 8:00 a.m. to 12:10 p.m. and 1:10 p.m. to 4:30 p.m., Monday through Friday.
You can also write to us to request a redetermination at the following address:
Redeterminations, Hearings & ALJs
Upstate Medicare Division
P.O. Box 5200
Binghamton, NY
13902-5200
Our office will obtain any additional data needed from your provider.
Medicare Part B Claims - Who Pays First?
At the Upstate Medicare Division, we get many calls regarding who pays first on your health claims when you or your spouse is employed and has coverage through an employer group health plan. Here's how Medicare determines who pays first (the primary payer) and who pays second (the secondary payer). Medicare is the secondary payer if you are age 65 or over and:
- You are covered under a group health plan because of your current employment or your spouse's current employment (your spouse can be any age), and
- The employer has 20 or more employees.
Medicare is also the secondary payer if you or your spouse are self-employed and covered by a group health plan of a firm that has 20 or more employees.
You may accept or reject the plan offered by the employer. If you accept the plan, and you meet the above requirements, the plan will be the primary payer. If you reject the plan, Medicare will be your primary payer.
If your group health insurance is your primary payer, be sure to tell your doctor and other health professionals so your bills can be sent to the group health plan first and delays in payment can be avoided.
Is there a change in your group health plan coverage that Medicare needs to know about?
Here are some examples of changes you will want to notify Medicare about:
- If you or your spouse retire, causing your group health plan to terminate or convert to a supplemental plan.
- If Medicare is your primary insurance and you or your spouse start working and you sign up for a group health plan that falls under the guidelines indicated above.
- If your or your spouse's employer changes to another group health plan while you or your spouse is still working.
Medicare sends out a questionnaire when your first Medicare claim is processed. Your responses to these questions are used in setting up your records, which indicate who your primary insurance is. Your records will continue to reflect the data you provided until Medicare receives new information.
By keeping Medicare updated regarding your employment status, you can help ensure that your claims are processed timely and accurately. To update your Medicare records regarding your primary insurer, you can write to the Upstate Medicare Division at the following address:
Medicare Secondary Payer Department
PO Box 5200
Binghamton, NY 13902-5200
You can also call 1-800-MEDICARE (1-800-633-4227) if you have questions. |
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Help With Your Medicare Costs - QMB, SLMB, QI, and QDWI Programs
There are four programs available under Medicaid and administered by local Social Service Departments to help certain elderly and disabled persons with low incomes to pay Medicare costs. You must be entitled to Medicare Part A. For information on whether you are entitled to Part A, check with any Social Security Administration Office or call 1-800-772-1213. If you qualify, you may not have to pay some or all of Medicare’s premiums, deductibles and coinsurance. These four programs are described below. Please note the QMB and SLMB programs are entitlements, which means that all beneficiaries who are eligible will receive the benefit. Funding for the QI-1 program is limited and payments are made on a first come, first served basis.
Qualified Medicare Beneficiary Program (QMB):
This program can pay for either the Medicare Part A or Part B premium. For payment of the Medicare Part A premium, applicants must conditionally enroll in Medicare Part A at their local Social Security Office. This program also pays for the Medicare Parts A and B coinsurance and deductibles (hospital deductible, daily coinsurance charges for extended stays in a hospital or skilled nursing facility, the 20% coinsurance for Medicare covered services). In this program, you would only be responsible for paying services and supplies which are not covered by Medicare (such as routine physicals, dental care, hearing aids, and eyeglasses).
Specified Low Income Medicare Beneficiary Program (SLMB):
This program pays for the Medicare Part B premium only. You would continue to be responsible for Medicare’s deductibles, coinsurance, and services which are not covered by Medicare. The applicant must have Medicare Part A to be eligible for the program.
Qualified Individual-1 (QI-1):
This program pays for the Medicare Part B premium only. The applicant must have Medicare Part A to be eligible for the program.
Qualified Disabled and Working Individual (QDWI):
This program pays for Medicare Part A premium only, not Part B. The applicant must be a disabled worker under age 65 who lost Part A benefits because of return to work.
How do I apply?
To learn if you qualify for QMB, SLMB, QI, or QDWI assistance, visit the New York State Office for the Aging Health Insurance Information, Counseling & Assistance Program (HIICAP) Web site at www.hiicap.state.ny.us/facts/ medicare_savings.htm. You must file an application with your local Department of Social Services. Check the county listings in your local phone book for the Medicaid, Social Services, or Medical Assistance Office nearest you, or call your local Office for Aging or Area Agency on Aging for assistance. Explain that you think you qualify for the QMB, SLMB, QI, or QDWI programs, and ask about when and where you can file an application. (Benefits may take approximately two to three months to be processed.)
When you file an application for QMB, you will be expected to have copies of bank statements, property deeds, and insurance policies, to show the amount of cash you have and the value of things you own. Money set aside for burial will not count toward your resource allowance. As your application is processed, be prepared to answer questions about your income, property you own, and other assets.
If your application is denied, or you need more assistance, you may want to contact your State Agency on Aging. In New York, you can refer to the New York State Office for the Aging, whose "Hotline" number is 1-800-342-9871.
For more information on these programs, visit the List and Definition of Dual Eligibles page on the CMS Web site at www.cms.hhs.gov. |
