How to File a Medicare Grievance - dummies

How to File a Medicare Grievance

By Patricia Barry

Copyright © 2015 AARP

A grievance covers many types of complaints that you can bring against your Medicare Advantage or Part D drug plan — but not those that have anything to do with coverage or payment. Instead, it can focus on any aspect of a plan’s service or quality of care that requires some action from the plan to resolve. Situations when you may want to file a grievance include

  • Poor or unsatisfactory customer service: Plan representatives leave you on hold for ages or disconnect your call, don’t respond to your questions satisfactorily, give wrong or inadequate answers, or are rude.

  • Misleading information: You choose a plan on the basis of information that turns out, after enrollment, to be untrue.

  • Absence of important notifications: The plan doesn’t send you notices required by law — such as its Annual Notice of Change — or you find the wording of its messages difficult to understand.

  • Problems at the pharmacy: A pharmacy in your plan’s network gives you the wrong meds or makes other mistakes in dispensing your drugs.

  • Poor quality of care for medical services: You can’t easily get appointments or have to wait too long for them. You have a problem with your care from doctors, nurses, hospitals, or other providers in the plan’s network — including rude behavior and facility cleanliness.

  • Tardy responses or decisions: The plan fails to respond to your request for a coverage determination or an appeal, or it doesn’t give you its decision within the required time frame.

To file a grievance, you can call or write to the plan about your complaint. Look at the informational materials your plan sent you when you enrolled. These documents give the appropriate phone numbers and address for filing a grievance, as well as instructions for how to go about it. You can also find this info on your plan’s website.

You must file the complaint within 60 days of the incident that prompted it. (You can request an extension for a good reason, such as illness or a family crisis. Send your plan an explanation in writing, even if the 60-day deadline has passed.) The plan must respond to your complaint within 30 days of receiving it, or up to 14 days more if the plan needs longer to investigate.

If the plan decides that no action is needed — in other words, it doesn’t think your complaint is justified — you can’t appeal any further. (An exception is if it’s a quality of care issue. In that case, you have the right to take it up with your Quality Improvement Organization (QIO). Alternatively, if the plan decides your complaint should be handled as a coverage determination, it must tell you how to go about doing that.