Medicare Advantage: HMO Special Rules

If you receive a bill for emergency or urgently needed care provided outside your Medicare Advantage Plan network, you should do two things:

• Write a letter to your Plan.
  • Explain the circumstances surrounding the charge.
  • Include the bill.
  • List the names of the doctors, ambulances, and other medical providers that may also be sending bills. A single trip to the Emergency Room will generate bills from: the hospital, the ambulance company, at least one and probably more doctors and possibly some outside laboratory charges.
  • If possible give the mailing addresses of all the providers if you were able to obtain them.
  • Keep a copy of the letter and all enclosures for your file.
• As a backup:
  • Call the group that billed you directly.
  • Ask them to submit bills directly to the Medicare Advantage Plan. Be sure you have the Plan's claims billing address before calling.
  • It is advisable to make notes of the conversation, including the name and direct number of the person with whom you spoke. File the notes with your information about your health plan.

If your Medicare Advantage Plan attempts to deny the coverage, it must list your rights of appeal in the denial letter. 

For information about appealing denials about a Medicare Advantage claim, click here.

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