Although Tel-Law information is periodically reviewed, it is important for you to realize that changes may occur in this area of law. This information is not intended to be legal advice regarding your particular problem, and it is not intended to replace the work of an attorney.

If you do not have an attorney, the Oregon State Bar Lawyer Referral Service can help you. Online Lawyer Referral Service information and a fill-in form is available. Or you may contact the service by phone: The number to call from the Portland area is 503-684-3763 or toll-free from anywhere else in Oregon, 1-800-452-7636.

The following information regarding medicare is brought to you as a public service by the lawyers of the State of Oregon. The material presented is general legal information intended to alert you to possible legal problems and solutions.

How Are Medicare Claims Handled?
Claims for health care payments under Medicare are handled by private insurance companies. In Oregon, Medicare Northwest handles Part A claims, and Noridian Mutual Insurance Company handles most claims under Part B. Medicare most often does not pay the full cost of most covered health care. Sometimes it improperly denies claims; sometimes a health care provider will mistakenly tell you that it cannot give you a service because Medicare does not cover the service. This misinformation can be very expensive for you if you do not act quickly to protect your rights.

What Can You Do If You Don't Agree With a Hospital's Decision About Your Need for Hospital Care?
When you are admitted to a hospital, you should receive a notice about your rights as a hospital patient. You have special appeal rights if you think you are being discharged from the hospital too soon. A hospital cannot use the amount of the Medicare payment under the Diagnostic Related Groups, or DRGS, to decide how long you need inpatient care. The DRGs represent average times for hospital stays. They do not take into account your personal rate of recovery or any other health problems you may have that have an impact on your condition.

To appeal the length of time allowed for your hospital stay, the hospital patient or their family must ask for a written notice of when the time is up. Once you get the notice and it seems unreasonable, you (or someone representing you) would call the Peer Review Organization (PRO), at the number on the notice as soon as possible to ask it to reconsider. You may be billed for all costs of your hospital stay beginning at noon of the day after you receive the PRO's decision, unless the PRO decides you still need hospital care. By that time, your condition may have improved enough for you to go home safely anyway. If it hasn't, you can get additional review. At this point, it will be important for your doctor to become involved in explaining your continuing medical needs.
The PRO for Oregon is the Oregon Medical Professional Review Organization (OMPRO). OMPRO's telephone number is (503) 279-0100 or 1-800-844-4354.
If the PRO agrees with the hospital's decision, you can ask for a reconsideration by contacting the PRO by phone or in writing. Since the PRO has already reviewed your case once, the hospital is permitted to begin billing you for the cost of your stay beginning with the third calendar day after you receive a Notice of Noncoverage.

If you disagree with the Peer Review Organization's decision on reconsideration, and the amount in dispute is $200 or more, you can ask for a hearing before an Administrative Law Judge from the Social Security Administration. You have 60 days from the day you receive the notice of the reconsideration decision to request a hearing in writing. If there is $2,000 or more in dispute, the administrative law judge's decision can be reviewed by a federal court. This process may change during the next year, as the Medicare appeals process is transferred to a new agency, the Center for Medicare and Medicaid Services, or CMS. Both the Social Security Administration and CMS can provide you with details on the new system when it is in place.

What If I Disagree With a Coverage Decision About My Medicare Benefits?
You may have questions or disagree with a decision about a Medicare payment. Medicare notifies you each time a decision is made on paying for services you received.

For a claim under Part A in Oregon, Medicare Northwest sends out a Medicare Benefit Notice. It will list any services that are not being covered by Medicare and gives the reasons payment was denied. You can call the office listed on the notice and request an explanation. If you disagree with the decision, you have 60 days from the date you received the denial notice to make a written request for reconsideration. You can send evidence to support your case. Your claim will be reviewed by Medicare Northwest, and you will get a reconsideration decision notice.

If you don't agree with the reconsideration decision, and the amount in dispute is $100 or more, you can ask for a hearing. You have 60 days from the date you received the reconsideration decision notice to make a written request for a hearing. The hearing will be held by an Administrative Law Judge from the Social Security Administration. You may have a lawyer or someone else represent you at the hearing. You may also bring evidence and witnesses to testify for you at the hearing. The Administrative Law Judge's decision can be reviewed by the Appeals Council of the Social Security Administration, and if the denial involves $1,000 or more, the denial may be appealed to federal court. This process may change somewhat when the Center for Medicare and Medicaid Services takes over the appeals process.

For a claim under Part B in Oregon, Noridian Mutual Insurance Company sends out an Explanation of Medicare Benefits. This notice includes a statement about your appeal rights. If you disagree with the decision, you have six months from the date of the notice to send in a written request for review. You can include new information or reports with the request. After your claim is reviewed by Noridian, you will receive a written explanation of its review determination.

If you don't agree with the review determination, and the amount in dispute is between $100 and $500, you can request a hearing. The hearing will be conducted by a hearing officer employed by Noridian. To meet the $100 requirement, you may combine claims. If the amount is over $500, you can ask for a hearing before an Administrative Law Judge from the Social Security Administration. You have 60 days from the day you receive the review determination to request a hearing in writing. To meet the $500 requirement, you may combine claims. If there is $1,000 or more in dispute, the Administrative Law Judge's decision can be reviewed by the federal court. When CMS takes over the appeals system, this process may change somewhat.

When a Health Maintenance Organization or HMO is involved, the process is different. If the HMO refuses to provide a service, you may need to ask for a written decision on your request for payment. You have 60 days from the date you received the denial notice to make a written request for reconsideration by the HMO. If the HMO supports the original denial, it must send your request to the Center for Health Dispute Resolution, which is located in New York. The Center for Health Dispute Resolution will send you a reconsideration decision notice.

If you don't agree with the reconsideration decision, and the amount in dispute is $100 or more, involving services under Part A or Part B or both, you can ask for a hearing. You have 60 days from the date you received the reconsideration decision notice to make a written request for a hearing with an Administrative Law Judge from Social Security. If there is at least $1,000 at issue, the decision by the Administrative Law Judge can be appealed to federal court.

If you need assistance understanding Medicare paperwork, submitting claims, or organizing your bills, you can get free help from the State of Oregon's Senior Health Insurance Benefits Assistance (SHIBA) program. To get assistance or referral to a SHIBA volunteer, call toll-free 1-800-722-4134.

What Can You Do If You Don't Agree With a Decision About Your Need for Skilled Care in a Nursing Home?
If you are admitted to a nursing home and Medicare is paying for skilled care, your condition will be reviewed frequently. If you are receiving rehabilitative services, the facility may refuse to continue them because you are not improving fast enough, for example. If you are told you no longer need or are no longer entitled to skilled care, you should receive a written notice explaining why, and telling you how to appeal the decision. If you think you still need skilled care at least five days per week, or if you think you need rehabilitation services to keep your condition from getting worse, you or someone representing you can call the Peer Review Organization (PRO) to ask it to reconsider. If the PRO upholds the nursing home decision, you may be billed for the cost of your nursing home stay after that. The telephone number for the PRO for Oregon is 503-279-0100 or 800 344 4354.

This information is from the Oregon State Bar's Tel-law service, a collection of recorded legal information messages prepared by the lawyers of Oregon. In addition to being online, the Tel-law service is accessible by telephone at 503-620-3000 or toll-free in Oregon only, 1-800-452-4776. A touch tone phone allows direct access 24 hours a day, 7 days a week. To receive a free Tel-law brochure listing the subjects available call 503-620-0222, ext. 0.