Medicare Appeals

Medicare Appeals

Pre-service Appeals (services have not been rendered) for contracted and non-contracted providers

• If this is regarding medical care benefits of coverage, please visit Medicare Member Medical Appeal Process.
• If this is regarding a prescription drug benefits or coverage, please visit Medicare Member Pharmacy Appeal Process.
• If this is regarding a hospital discharge appeal by a contracted provider, click here.
• If this is regarding a hospital discharge appeal by a non-contracted provider, click here.
• If this is a discharge appeals for home health, a skilled nursing facility or rehabilitation facility, click here.

Payment appeals for non-contracted providers

• Non-contracted providers can appeal decisions regarding payment when a valid Waiver of Liability is completed and submitted to the Plan. This appeal process applies to all of our medical benefits plans.
• If you received zero payment or a payment on a claim that you are not disputing the rate you would have received under original medicare, please visit Medicare Member Medical Appeal Process.
• Reference materials:
  • Medicare non-contracted provider appeal process (PDF)
  • Medicare member payment appeal post service (PDF)
• If you have a dispute around a payment you would have received under original Medicare please send your dispute, along with documention of what original Medicare would have paid, applicable copies of medical records and an explanation of why you disagree with the decision to:

Medicare Provider Disputes
P.O, Box 14067
Lexington, KY 40512

Payment appeals for contracted provider requests

If you have a dispute around the rate used for payment you have received, please visit Health Care Professional Dispute and Appeal Process.

Discharge appeals for home health, skilled nursing facility, or rehabilitation facility care

All Medicare patients, their legal representative or physician may appeal the discontinuation of services being rendered by a home health agency, skilled nursing facility, or rehabilitation care facility.

The Quality Improvement Organization (QIO) is the first level of appeal for these requests. The QIO must be contacted by noon the following day of the Notice of Medicare Non Coverage (NOMNC) being issued. The applicable QIO reviews the decision to discontinue services. The applicable QIO can be located at http://qioprogram.org/contact-zones.

• The QIO will contact the hospital staff and the Plan to get medical records for review.
• The hospital may be asked to share clinical information with a member of Innovation Health’s Medicare Advantage Fast Track Team to complete the CMS-required Detailed Notice of Discharge.

If a Medicare member asks for the review after the required timeframe, the Medicare expedited appeal process will apply. Refer to Medicare Member Medical Appeal Process for how to file an expedited appeal.

For more information regarding the appeal process, please call 1-866-269-3692.

Inpatient hospital discharge appeals for contracted facilities  

Please visit Health Care Professional Dispute and Appeal Process.

Inpatient hospital discharge appeals for non-contracted facilities

If a Medicare member asks for the review after midnight on the day of discharge or after leaving the hospital, please visit Medicare Member Medical Appeal Process.

Hospital discharge appeal notices (CMS website)