Keep complaints and appeals separate
A complaint addresses service, access, conduct, quality, or process. A coverage or payment denial usually requires an appeal. Complete both routes when the facts create both issues.
1. Classify the issue
- Write the service, access, treatment, quality, communication, or process problem.
- Identify any separate coverage or payment denial that requires an appeal.
- Read every notice for a shorter or separate deadline.
2. Identify the responsible plan
- Plan name and type: Medicare Advantage, other Medicare health plan, or Part D plan.
- Member-services and grievance contact from the membership card or Evidence of Coverage.
- Official Medicare Complaint Form when you choose the Medicare.gov route.
3. Record the incident
- Date, time, location, and people involved.
- What happened and how it affected access, service, care, or rights.
- Names, reference numbers, and summaries of calls or messages.
4. Protect the deadline
- Calculate the general 60-calendar-day filing period from the event or incident.
- Do not wait for a related appeal to finish.
- Keep proof showing when the grievance was submitted.
5. Gather supporting material
- Plan notices, portal messages, letters, appointment records, or call logs.
- Statements from a provider or witness when relevant.
- Receipts or other records that document the problem.
- Representative authorization if another person is filing.
6. State the requested resolution
- Ask for a clear investigation and explanation.
- Identify a practical correction, such as accessible communication, an appointment, corrected information, or staff follow-up.
- Do not rely on a grievance alone to overturn a coverage denial.
7. Check the narrow 24-hour rule
- For Medicare Advantage, determine whether the grievance concerns a plan extension or refusal to expedite an organization determination or reconsideration.
- For Part D, determine whether it concerns refusal to expedite a coverage determination or redetermination before the drug was purchased or received.
- Ask the plan to identify the applicable grievance timeframe in writing.
8. Track the response
- Record the date the plan received the complaint.
- Calendar the general 30-day response limit.
- Save any written notice of an extension of up to 14 calendar days.
- Contact 1-800-MEDICARE or SHIP if the grievance is not addressed.