Medicare Managed Care Appeals and Grievances

A grievance is an expression of dissatisfaction (other than an organization determination) with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers, regardless of whether remedial action is requested.  The enrollee must file the grievance either verbally or in writing no later than 60 days after the triggering event or incident precipitating the grievance.

Examples of grievance include:

• Problems getting an appointment, or having to wait a long time for an appointment
• Disrespectful or rude behavior by doctors, nurses or other plan clinic or hospital staff

Each plan must provide meaningful procedures for timely resolution of both standard and expedited grievances between enrollees and the Medicare health plan or any other entity or individual through which the Medicare health plan provides health care services.  Plans  must notify all concerned parties upon completion of the investigation as expeditiously as the enrollee's health condition requires, but no later than 30 days after the grievance is received, unless in the best interest of the enrollee the timeframe is extended by the plan for up to 14 calendar days.

However, the plan must respond to a grievance within 24 hours if:

1. The complaint involves a plan’s decision to invoke an extension relating to an organization determination or reconsideration.
2. The grievance involves a refusal by the plan to grant an enrollee's request for an expedited organization determination or expedited reconsideration.

Quality of care grievances (complaints about the quality of care received in hospital or other provider settings) may be reported through the plan's grievance procedures, the enrollee's Beneficiary Family Centered Care - Quality Improvement Organization (BFCC-QIO), or both. 

For more information about the grievance process, see section 30 in the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the “Downloads” section below. A copy of the model notice plans may use to notify enrollees about their right to an expedited grievance can be found at “Notices and Forms” using the left navigation menu on this page.  

For more information about filing a grievance with the BFCC-QIO, click on the link to the Medicare publication “Medicare Rights and Protections” under the "Related Links" section below.