COMPLAINTS and APPEALS

What is a Complaint?

A complaint is a statement that a situation is unsatisfactory or unacceptable. In healthcare, it can be about the quality of care you got or are getting.

For example, you can file a complaint if you have a problem calling the plan, or you're unhappy with how a staff person at the plan treated you.

What is an Appeal?

An appeal is to make a serious or urgent request, typically to the public. You file an appeal if you have an issue with a plan's refusal to cover a service, supply, or prescription.

Filing a Complaint

If you have concerns about the quality of care or other services you get from a Medicare provider and if you are not satisfied, you can always file a complaint. How you will file depends on what your complaint is all about.

It can either be:

A doctor, hospital, or provider
Your health or drug plan
Quality of your care
Your dialysis or kidney transplant care
Durable medical equipment

If you need help filing a complaint, you can
contact your State Health Insurance Assistance Program (SHIP) for free personalized help.

Filing an appeal

You can appeal if Medicare or your plan denies one of these:

Your request to get a health care service, item, or
the drug you think should be covered, provided, or continued.
Your request for payment for a health care service, item, or drug you already got.
Your request to change the amount you pay for a health care service, item, or drug

If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights.

You can find your plan's contact information on your plan membership card. Or, you can search for your plan's contact information.

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.

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