It's important to know the difference between an appeal and a grievance.

A Medicare appeal is when a caller seeks to remedy a Medicare decision regarding coverage, payment, or discharge when it should be a covered service.

A grievance is when a caller wants to know why a particular service is not covered under Medicare (non-covered services) and they are unhappy with the process or actions of the provider. 

For example, if a person was transported from assisted living to the emergency room via ambulance at the suggestion of the assisted living case manager but the doctor determined that nothing was wrong with the beneficiary and they prescribed them over-the-counter medicine for general pain, the ambulance would not be covered because it wasn't considered a true emergency by Medicare and they could have travelled by car, taxi, etc. This is not an appeal for the denied Medicare claim but the person could file a complaint against the facility. 

Obtain information regarding the appeal including: 

• Date of service
• Name and phone number of provider of the service
• Reason for the denial and who is denying
• What specifically is being appealed
• Do they have Original Medicare, Advantage Plan, Cost Plan, or Part D plan?
• Do they have a copy of their Medicare Summary Notice, Explanation of Benefits, or other denial notice readily available? 

After obtaining this information, warm transfer the call to Tier 3 support queue to consult if this is an appeal or an appealable service.
If it is, Tier 3 staff will take over the case, if it is not, staff should continue providing assistance including screening for financial supports, providing resources and other appropriate assistance.

If Tier 3 believes this is an appeal, transfer the call directly to that staff and transfer ownership of the CTS case to them. 

Example of reasons to appeal:

• A request for a health care service, supply, item, or drug the caller thinks Medicare should cover.
• A request for payment of a health care service, supply, item, or drug that the caller already got. 
• A request to change the amount the caller must pay for a health care service, supply, item, or drug.
• If Medicare or the caller's plan stops providing or paying for all or part of a health care service, supply, item or drug they think they still need. 
• If a Medicare beneficiary is going to be discharged from a hospital, swing bed, or SNF and they feel that it is too soon.
• An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines. 
• Part D medication is not on the plan's formulary. 

Use this link for more information about Medicare appeals.