Use a complaint or grievance when you are dissatisfied with service, access, conduct, quality of care, or how a plan handled a process. Use an appeal when you disagree with a coverage or payment decision.
Use a complaint for plan-service problems
Examples include rude treatment, long appointment waits, difficulty reaching customer service, confusing written materials, trouble accessing a specialist, quality-of-care concerns, or a problem with how an appeal was handled.
Use an appeal for an unfavorable decision
Appeal when Original Medicare, a Medicare Advantage plan, or a Part D plan refuses to authorize, provide, cover, or pay for an item, service, or prescription drug. The denial notice identifies the correct appeal route and deadline.
You may need both
Suppose a Medicare Advantage plan denies prior authorization and customer service repeatedly gives inaccurate instructions. The coverage denial belongs in the appeal. The customer-service problem may be filed separately as a grievance. Filing the grievance does not stop the appeal deadline.
Other complaints may use a different office
A quality-of-care complaint can go to the plan, the BFCC-QIO serving your state, or both. Complaints about nursing-home conditions, facility safety, professional conduct, dialysis care, or another provider may use a State Survey Agency, licensing board, ESRD Network, or another official channel.
When you are unsure
Read the plan notice and membership materials, contact the plan, or call 1-800-MEDICARE. A SHIP counselor can explain the available routes without representing an insurance company. Protect the shortest stated deadline while you seek help.