A grievance is any complaint or dispute (other than an organization determination) expressing dissatisfaction 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 orally or in writing no later than 60 days after the triggering event or incident precipitating the grievance.
Listed below are some examples of problems that are typically dealt with through the plan grievance process:
- 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 hearing and resolving 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.
The Medicare health plan must include in its grievance procedures:
- The ability to accept any information or evidence concerning the grievance orally or in writing not later than 60 days after the event; and
- The requirement to respond within 24 hours to an enrollee's expedited grievance whenever:
- A Medicare health plan extends the time frame to make an organization determination or reconsideration; or
- A Medicare health plan refuses to grant a request for an expedited organization determination or reconsideration.
Plans must notify all concerned parties upon completion of the investigation as expeditiously as the enrollee's case requires based on the enrollee's health status, but not later than 30 days after the grievance is received.
For more information about the grievance process, see section 20.3 in Chapter 13 of the Medicare Managed Care Manual. A copy of the model notice plans may use to notify enrollees about their right to an expedited grievance is located in Appendix 5. Click on the “Downloads” section below to access Chapter 13.
Grievances about Part D prescription drugs are not processed using these procedures. For information on how to file a grievance about prescription drugs, click on the link to Chapter 18 of the Prescription Drug Benefit Manual under the "Downloads" section below.
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 Quality Improvement Organization (QIO), or both.
For more information about filing a grievance with the QIO, click on link to the Medicare publication 11534 – “Medicare Rights and Protections” under the "Related Links" section below.
- Chapter 13 - Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health Plans) [PDF, 426KB]
- Chapter 18 of the Prescription Drug Benefit Manual [ZIP, 1MB]
- Page last Modified: 10/08/2014 8:33 AM
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