Grievances

A grievance is any complaint or dispute, other than one that involves a coverage determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested.

Examples of grievances include problems with customer service, if an enrollee disagrees with a plan sponsor's decision not to expedite a request for a coverage determination or redetermination; or if an enrollee believes the plan sponsor's notices and other written materials are difficult to understand.

An enrollee or an enrollee's representative may file a grievance with the plan sponsor.

Grievances may be filed orally or in writing.

A grievance must be filed with the plan sponsor no later than 60 days after the event or incident that brought about the grievance.

In general, the Part D plan sponsor must notify the enrollee of its decision as expeditiously as the enrollee's health requires, but no later than 30 days after the date the Part D plan sponsor receives the grievance, unless extended by the plan for up to 14 calendar days.

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

(1) the grievance involves a refusal by the Part D plan sponsor to grant an enrollee's request for an expedited coverage determination or expedited redetermination, and

(2) the enrollee has not yet purchased or received the drug that is in dispute.