Complaints, grievances, and beneficiary resources

What is a grievance?

A grievance is a formal complaint that you file with your plan. If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is not an appeal, which is a request for your plan to cover a service or item that it has denied. Times when you may wish to file a grievance include if your plan has poor customer service or you face administrative problems.

Some examples of issues that might lead you to file a grievance include:

• Your plan fails to return a coverage determination or appeal decision on time
• Your plan fails to expedite a coverage determination or appeal
• You experience poor quality of care from an in-network provider
• You experience poor customer service from a plan representative
• You are asked to pay an incorrect copayment amount
• You are involuntarily disenrolled from your plan
• There is a change in premiums or cost-sharing
• You receive inadequate written communications from your plan
• You experience marketing abuse

To file a grievance, send a letter to your plan’s Grievance and Appeals department. Visit your plan’s t them by phone for the address. You can also file a grievance with your plan over the phone, but it is recommended to send your complaints in writing. Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.

In some cases, you may want to file both an appeal and a grievance. To file a grievance, send a letter to your plan’s Grievance and Appeals department. Visit your plan’s website or contact them by phone for the address. You can also file a grievance with your plan over the phone, but it is recommended to send your complaints in writing. Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.

Who should I contact if…

• I have a quality of care concern?
• Call your BFCC-QIO if the concern is about a physician, inpatient hospital, hospital outpatient department, hospital emergency room, skilled nursing facility, home health agency, or ambulatory surgery center. Find your BFCC-QIO by visiting www.qioprogram.org/contact.
• Call your ESRD Network Organization if the concern is about a dialysis or kidney transplant center. Find your ESRD Network Organization by visiting www.esrdnetworks.org.
• I have a complaint about my Medicare Advantage or Part D prescription drug plan? Call 1-800-MEDICARE to file a complaint.
• I have a complaint about my durable medical equipment supplier? Call your supplier to submit your complaint. You can also call 1-800-MEDICARE.
• I suspect that a provider or Medicare private plan is engaging in Medicare fraud, abuse, or misleading marketing?
• Contact your provider or plan first to clarify and check if they made a billing error.
• Your Senior Medicare Patrol (SMP). Find your SMP by calling 877-808- 2468 or visiting
  www.smpresource.org.
• The Inspector General’s Medicare fraud helpline. Call 1-800-HHS-TIPS (1 -800-447-8477).
• I have questions about my Medicare Part A or B enrollment or my Social Security Benefits? Visit your local Social Security Administration (SSA) office or call the SSA helpline at 1-800-772-1213.
• I have questions about Medicare benefits and plan enrollment? Call 1-800- MEDICARE or visit www.mymedicare.gov.
• I need help enrolling in low-income programs, appealing a denial in service, choosing a new plan, or understanding my benefits? Contact your local State Health Insurance Assistance Program by calling 877-839-2675 or visiting www.shiptacenter.org.

This content was created and copyrighted by the Medicare Rights Center ©2019. Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities. These materials are presented here with support from YourMedicare.com and may not be distributed, modified or edited without Medicare Rights’ consent.