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上诉-医疗保险合格受益人

你是否应该被拒绝为健康索赔或服务提供保险, you will be notified in writing and will be provided with information on the Funds’ appeal procedure. 下面的信解释了皇冠搏彩中心网站的上诉程序.

The Centers for Medicare & Medicaid Services (CMS) has regulations governing your right to file a Medicare Appeal. As a Medicare-eligible beneficiary of a health plan administered by the 保健和退休皇冠搏彩中心网站 (the “Funds”), 你有权提出医疗保险上诉. 您的申诉权利包括针对某项服务的标准30个日历日申诉, 标准的60日历日付款申诉和72小时加急申诉. 本通知告知您当前的医疗保险上诉程序. In addition, we provide you with useful information when filing a standard or expedited appeal.

You Have a Right To Appeal

You can appeal if you do not agree with the Funds’ decision about your medical bills or health care. 如果你认为:

  • The Funds has not paid a bill
  • 皇冠搏彩中心网站没有全额支付账单
  • 皇冠搏彩中心网站不会批准或给予你它应该涵盖的照顾
  • 皇冠搏彩中心网站会停止了你仍然需要的护理

The Funds normally has 30 calendar days to process your appeal for service and 60 calendar days to process your appeal for a payment. 在某些情况下,你有权在72小时内上诉. You can get a fast appeal if your health or ability to function could be seriously harmed by waiting 30 calendar days for a standard appeal. 如果你要求快速上诉,皇冠搏彩中心网站组织将决定你是否获得72小时快速上诉. 如果没有,你的上诉将在30个日历天内处理. If any doctor asks the Funds to give you a fast appeal or supports your request for a fast appeal, the Funds must give it to you.

Standard Appeal

有两种标准的申诉

1. 服务的标准申诉(30个日历日):
The Funds is responsible for processing your appeal request for service within 30 calendar days from the date the Funds receives your request or no later than the last day of the extension (up to 14 calendar days). 即使你可以向社会保障局提出申请, 该办事处将把您的请求转交皇冠搏彩中心网站处理.

14-day extension
An extension up to 14 calendar days is permitted for a 30 calendar day appeal if the extension of time benefits you; for example, 如果您需要时间向皇冠搏彩中心网站提供更多信息 or if we need to have additional information. You will be notified in writing if the Funds need additional time (up to 14 calendar days) to process your request. You have the right to file an expedited grievance if you disagree with the Funds’ decision to grant itself an extension.

2. 标准(60个日历日)付款申诉
The Funds is responsible for processing your appeal request for payment within 60 calendar days from the date the Funds receives your request.

如何提出标准上诉

1. File the request in writing, in person or by mail, 或通过电话与皇冠搏彩中心网站或社会保障局办公室联系.

2. 向皇冠搏彩中心网站提出的书面请求应邮寄至:

保健和退休皇冠搏彩中心网站
PO Box 292167
Nashville, TN 37229

3. 书面请求可传真至皇冠搏彩中心网站 1-800-382-7792.

4. 电话请求可以通过电话提出 1-800-292-2288.

5. 在通知发出之日起60个日历日内提交请求.

What happens next?

For a 30 calendar day appeal:
如果皇冠搏彩中心网站不支持你, 皇冠搏彩中心网站会将把您的申诉请求转交给医疗保险中心 & Medicaid Independent Review Entity for a decision within 30 calendar days from the date the Funds received your request.

For a 60 calendar day appeal:
如果皇冠搏彩中心网站不支持你, 皇冠搏彩中心网站会将把您的申诉请求转交给医疗保险中心 & Medicaid Services Independent Review Entity for a decision within 60 calendar days from the date the Funds received your request.

Expedited/72-Hour Appeal

加急上诉在72小时内处理,不适用于拒绝付款.

14-Day Extension
An extension up to 14 calendar days is permitted for a 72-hour appeal if the Funds determines that an extension of time benefits you or if you request an extension; for example, 如果您需要时间向皇冠搏彩中心网站提供更多信息. You will be notified in writing if the Funds need additional time (up to 14 calendar days) to process your request. You have the right to file an expedited grievance if you disagree with the Funds decision to grant itself an extension.

如何提出加急上诉

1. 提出口头或书面请求,进行72小时的上诉. 具体说明“我想要加速上诉。, fast appeal or a 72-hour appeal” or “I believe that my health could be seriously harmed by waiting 30 calendar days for a normal appeal.”

2. 口头提出请求,打电话 1-800-292-2288. 各皇冠搏彩中心网站将以书面形式记录口头请求.

3. 如需亲自递交申请,皇冠搏彩中心网站的地址为:
保健和退休皇冠搏彩中心网站
801 Royal Parkway 3rd Floor
Nashville, TN 37214

4. 要传真您的请求,皇冠搏彩中心网站的传真号码是1-800-382-7792. 如果你在医院或护理机构, you may request assistance in having your written appeal transmitted to the Funds by use of a FAX machine.

5. 邮寄书面请求,我们的地址是:
保健和退休皇冠搏彩中心网站
PO Box 292167
Nashville, TN 37229

6. 在收到您的上诉请求之前,72小时的审查时间不会开始.

7. 你必须在通知发出之日起60个日历日内提交你的请求.

What happens next?

If the Funds denies your request for an expedited appeal: the request will be processed within 30 calendar days or no later than the last day of the extension (up to 14 additional calendar days) from the date the Funds received your request for an expedited appeal. 您有权在以下地址向皇冠搏彩中心网站提出加急申诉 1-800-291-1425, 如果皇冠搏彩中心网站拒绝你的快速上诉请求.

If the Funds approves your request for an expedited appeal: the Funds will make a decision on your appeal and notify you of it within 72-hours of receipt of your request. 如果我们的决定不完全对你有利, 我们会自动将您的申诉请求转发给医疗保险中心 & Medicaid Services Independent Review Entity for an independent review within 24 hours of receipt of your request. Centers for Medicare & Medicaid Services Independent Review Entity will send you a letter with their decision within 72 hours of receipt of your case from the Funds.

Support for Your Appeal, Who May File an Appeal, Help With Your Appeal, 和同行评审组织投诉流程

以下信息适用于标准上诉和快速上诉

Support for Your Appeal

You are not required to submit additional information to support your request for services or payment for services already received. 皇冠搏彩中心网站负责收集所有必要的医疗信息, however, it may be helpful to you to include relevant medical records or physician opinions in support of your appeal. 要获得医疗记录,请向您的初级保健医生发送书面请求. If your medical records from specialist physicians are not included in your medical record from your primary care physician, you may need to make a separate written request to the specialist physician(s) who provided medical services to you.

Who May File an Appeal?

  • You may file an appeal.
  • 如果你想让别人为你提出上诉:
    • Give us your name, your Medicare number, 以及一份声明,指定一个人作为你的代表. (注:你可以指定你的医生.) For example “ I (your name) appoint (name of representative) to act as my representative in requesting an appeal from the Funds and/or the Centers for Medicare & Medicaid Services regarding the Funds’ (denial of services) or denial of payment for services).
    • 你必须在声明上签名并注明日期.
    • Your representative must also sign and date this statement unless he/she is an attorney.
    • 在你的上诉中附上这份签署的声明.
  • A non-plan doctor may file a standard appeal of a denied claim if he/she completes a waiver of liability statement which says he/she will not bill you regardless of the outcome of the appeal.
  • A court-appointed guardian or an agent under a health care proxy to the extent provided under state law.

Help With Your Appeal

如果你决定上诉并需要帮助, you may have your doctor, a friend, lawyer, or someone else help you. 有几个小组可以帮助你. 你可以联系地区老龄机构, the Insurance, 咨询和援助计划, 医疗保险权利中心免费电话 1-800-466-9050. 您的皇冠搏彩中心网站健康呼叫中心(1-800-291-1425) can also help you.

The Funds’ Health Call Center provides prompt responses to your questions and concerns. We encourage you to contact us whenever you have a question or concern about your plan or physician. 我们将与您合作,回答您的问题,并迅速解决您的问题.
随时联系健康呼叫中心免费电话 1-800-291-1425, if you have any questions.

We are here to help!