April 2022: Grievances, Complaints, 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 account
  • 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 a potential marketing violation or enrollment fraud

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.

Your plan must investigate your grievance and get back to you within 30 days.

  • If you made your request in writing, the plan must respond in writing.
  • If you made your request over the phone, your plan may respond verbally or in writing, unless you specifically request a written response.
  • If your request is urgent, your plan must respond within 24 hours.
  • If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan or 1-800-MEDICARE.

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 on qioprogram.org/locate-your-qio.
  • Call your ESRD Network Organization if the concern is about a dialysis or kidney transplant center. Find your ESRD Network Organization by visiting esrdnetworks.org.

I have a complaint about my Medicare Advantage or Part D prescription drug plan?

  • Call 1-800-MEDICARE to file a complaint after submitting a grievance to the plan.

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 potential fraud, abuse, or marketing violations by a Medicare provider or plan?

  • Contact your provider or plan first to clarify and see if they made an error.
  • Contact your Senior Medicare Patrol (SMP) by calling 877-808-2468 or visiting smpresource.org.

I have questions about my Medicare Part A or B enrollment or my Social Security Benefits?

  • Call the Social Security Administration (SSA) helpline at 1-800-772-1213.
  • Visit or call your local SSA office.

I have questions about Medicare benefits and plan enrollment?

  • Contact your broker or reach out to us if you do not have one.