
YOUR RIGHT OF APPEAL

     If you disagree with a decision on the amount Medicare will
pay on a claim or whether services you received are covered by
Medicare, you have the right to appeal the decision.  The notice
you receive from Medicare which tells you of the decision made on
a claim will also tell you exactly what appeal steps you can
take.  If you ever need more information about your right to
appeal and how to request it, call Social Security, the Medicare
intermediary or carrier, or the Peer Review Organization (PRO) in
your State.
(Medicare carriers are listed on pages XX to XX.  PROs are listed
on pages XX to XX)

     This section contains information on the following types of
appeals:
     *    Appealing Decisions Made by Providers of Services
          on Your Medicare Hospital Insurance Claims  
     *    Appealing Decisions Made by Peer Review Organizations
          (PROs) 
     *    Appealing Decisions Made by Medicare Intermediaries on
          Your Hospital Insurance Claims 
     *    Appealing Decisions Made by Medicare Carriers on Your
          Medical Insurance Claims. 
     *    Appealing Decisions by Health Maintenance Organizations
          (HMOs) or Competitive Medical Plans (CMPs).   

APPEALING DECISIONS MADE BY PROVIDERS OF SERVICES ON YOUR
MEDICARE HOSPITAL INSURANCE CLAIMS
     In many cases the first written notice of noncoverage you
receive will come from the provider of the services (for example,
a hospital, skilled nursing facility, home health agency or
hospice).  This notice of noncoverage from the provider should
explain why the provider believes Medicare will not pay for the
services.  This notice is not an official Medicare determination,
but you can ask for an official Medicare determination.  If you
ask for an official Medicare determination, the provider must
file a claim on your behalf to Medicare.  When you receive the
official Medicare determination, if you still disagree, you can
appeal.
APPEALING DECISIONS MADE BY PEER REVIEW ORGANIZATIONS (PROs)
     When you are admitted to a Medicare participating hospital,
you will be given An Important Message From Medicare (see page xx
for a copy of the message).  The message contains a brief
description of PROs, and the name, address, and phone number of
the PRO in your State.  Also, it describes your appeal rights.
     PROs make determinations about hospital care and ambulatory
surgical center care.  The PROs decide whether care provided to
Medicare patients is medically necessary, provided in the most
appropriate setting, and is of good quality.  When you disagree
with a PRO decision about your case, you can appeal by requesting
a reconsideration.  Then, if you disagree with the PRO's
reconsideration decision, and the amount in question is $200 or
more, you can request a hearing by an Administrative Law Judge. 
Cases involving $2,000 or more can eventually be appealed to a
Federal Court.
NOTE:  In the case of elective or non-emergency surgery, either
the hospital or the PRO may be involved in pre-admission
decisions.  If the hospital believes that your proposed stay will
not be covered by Medicare, it may recommend, without consulting
the PRO, that you not be admitted to the hospital.  If this is
the case, the hospital must put its decision in writing.  If you
or your physician disagree with the hospital's decision, you
should make a request to the PRO for immediate review.  You must
make your request, by telephone or in writing,  within three
calendar days after receipt of the notice.
APPEALING DECISIONS MADE BY INTERMEDIARIES ON YOUR MEDICARE
HOSPITAL INSURANCE CLAIMS
     Appeals of decisions on most other services covered under
Medicare hospital insurance (skilled nursing facility care, home
health care, hospice services, and a few inpatient hospital
matters not handled by PROs) are handled by Medicare
intermediaries.  If you disagree with the intermediary's initial
decision, you have 60 days from the date you receive the initial
decision to request a reconsideration.  The request can be
submitted directly to the intermediary or through Social
Security.  If you disagree with the intermediary's
reconsideration decision and the amount in question is $100 or
more, you have 60 days from the date you receive the
reconsideration decision to request a hearing by an
Administrative Law Judge.  Cases involving $1,000 or more can
eventually be appealed to a Federal Court.
APPEALING DECISIONS MADE BY CARRIERS ON YOUR MEDICARE MEDICAL
INSURANCE CLAIMS
     Under Medicare medical insurance, either you, your doctor,
or your supplier submits the claim for payment.  (For services on
or after September 1, 1990, your doctor, supplier, or other
Medicare medical insurance provider of services must submit
claims to Medicare for you.  See page xx).  Medicare will send
you an explanation of the claim decision on a form called An
Explanation of Medicare Benefits (EOMB).  (See page xx for a copy
of this form.)  The form also explains how you can appeal denials
or payment decisions with which you disagree, and gives the name,
address, and Statewide toll-free number of the carrier.  (See
also pages xx to xx for a list of carriers and the areas they
serve.)
     If your physician is a non-participating physician, he or
she must provide you with a written notice in certain
circumstances.  If your physician knew or should have known that
a particular service would not be considered reasonable and
necessary under the Medicare program, he or she must give you
written notice, before performing the service, of the reasons why
he or she believes Medicare will not pay.  This type of notice is
not an official Medicare determination.  If you receive the
services in question, you may still submit a claim for payment to
Medicare.  You then have the right to appeal the Medicare
decision if you still disagree.
     If you disagree with the decision on your claim, you have
six months from the date of the decision to ask the carrier to
review it.  Then, if you disagree with the carrier's written
explanation of its review decision and the amount in question is
$100 or more, you have six months from the date of the review
decision to request a hearing before a carrier hearing officer. 
(Generally, to reach the $100 amount, you can count other claims
the carrier has reviewed within the past 6 months--if you
disagree with the carrier's decision on them.)
     If you disagree with the carrier hearing officer's decision
and the amount in question is $500 or more, you have 60 days from
the date you receive the decision to request a hearing before an
Administrative Law Judge.  Cases involving $1,000 or more can
eventually be appealed to a Federal Court.
APPEALING DECISIONS MADE BY HEALTH MAINTENANCE ORGANIZATIONS
(HMOs) AND COMPETITIVE MEDICAL PLANS (CMPs)
     If you are a member of an HMO or CMP with a Medicare
contract, decisions about coverage and payment for services will
usually be made by your HMO/CMP.  Your appeal rights are similar
to the rights of Medicare beneficiaries under traditional
fee-for-service Medicare.  Also, Federal law requires HMOs and
CMPs under contract to Medicare to provide a full, written
explanation of appeal rights to all members at the time of
enrollment, and at least once a year thereafter.  If you are a
member of an HMO or CMP and you have not received a written
explanation of your appeal rights, you should request one from
your organization's membership office.  