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Ashford Insurance

How to File a Grievance

Picture of Sonia Ashford

Sonia Ashford

Sonia Ashford is the owner of Ashford Insurance, an independent health insurance agency specializing in Texas Medicare insurance.

If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance.

How to File a Grievance

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 a formal complaint that you file with your plan. It is not an appeal, which is a request for your plan to cover a service or item it has denied.

Times when you may wish to file a grievance, include:

  • If your plan has poor customer service
  • You face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund)
  • You believe the plan’s network of providers is inadequate

You can file a complaint about:

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

To file a grievance:

You can file a complaint if you have concerns about the quality of care or other services you get from a Medicare provider. How you file a complaint depends on what your complaint is about.

Send a letter to your plan’s Grievance and Appeals department. Check 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 best 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.

You may also want to send a copy of the grievance to your regional Medicare office and to your representatives in Congress if you feel they should know about the problem. Go to www.medicare.gov or call 1-800-MEDICARE to find out the address of your regional Medicare office.

Keep a copy of any correspondence for your records.

Your plan must investigate your grievance and get back to you within 30 days. If your request is urgent, your plan must get back to you 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.

What’s the difference between a complaint and an appeal?

A complaint is 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.

You file an appeal if you have an issue with a plan’s refusal to cover a service, supply, or prescription.

Note:

For questions about a specific service you got, look at your Medicare Summary Notice (MSN) or log into your secure Medicare account. You can file an appeal if you disagree with a coverage or payment decision made by one of these:

  • Medicare
  • Your Medicare health plan
  • Your Medicare drug plan
 
 
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Picture of Sonia Ashford

Sonia Ashford

Sonia Ashford, “The Medicare Insurance Lady”, has been helping Medicare eligibles in Texas with their Medicare Insurance since 2005.