How to make a complaint or file an appeal about your Medicare coverage

There are two types of processes for handling problems and concerns. Your member contract, Evidence of Coverage, Member Handbook or Summary of Coverage and Disclosure includes detailed information about each process. The process you use depends on the kind of problem you are having: 

Coverage decisions and appeals

Use this process if the problem is about coverage or payment for medical services or prescription drugs. 

For example, you ask for coverage decisions to find out:

• Whether your plan covers a service or drug before you receive care
• How much coverage your plan provides for a service
• How much we will pay for a medical service or drug

You can also ask us to review or change a coverage decision we make by filing an appeal.

Complaints process

Use this process if the problem is not related to benefits or coverage. 

For example, you can make a complaint about:

• Quality of care
• Waiting times
• Customer service
• Cleanliness
• Privacy protection
• Information you get from us
• Time it takes to receive a coverage decision from us

You can ask us about what medical services we will cover. You can also ask us to change a decision we make about your benefits and coverage. 

Ask for a coverage decision before you receive a medical service. We will tell you if we cover it and how much we will pay.

If your health requires it and you need a quick response, ask for a fast decision. We will answer within 72 hours after we receive your request. For a standard coverage decision, we will answer within 14 calendar days after we receive your request. 

File an appeal if we have told you we will not cover or pay for a medical service in the way you want. We will review the decision and let you know if we will change it or not.

If your health requires it, you can request a fast appeal for a service you have not already received. We will give you an answer within 72 hours after we receive your request. If your appeal requires more time for review, we may take up to 14 calendar days to give you an answer.

For standard appeals, we will answer within 30 calendar days after we receive your request. If your appeal requires more time for review, we may take up to 14 additional calendar days to give you an answer. For appeals related to payment for services you have already received, we will answer within 60 calendar days after we receive your request.

If we say no to all or part of your appeal, you can choose to take your appeal further. There are five levels of appeal. Refer to your plan documents for more information.

You can make a complaint about the quality of care you receive, waiting times, customer service and other concerns. Making a complaint is also known as “filing a grievance.” 

There are two steps to file a complaint:

1. Contact us promptly by phone or in writing.

• Call the customer service number on the back of your ID card. If you need to take additional steps, we’ll let you know.
• If you prefer, you can explain the problem in writing and ask us to resolve it. You must mail your complaint to us within 60 days of the event. Mailing addresses listed below.

2. We look into your complaint and give you an answer.

• In cases where your health may be at risk, you can ask for a fast decision. We will answer within 24 hours of receiving your complaint and tell you if we agree with it or not. 
• For standard complaints, we will answer your complaint within 30 calendar days after we receive it. If we need extra days, we will tell you in writing. We can take up to 14 more calendar days to answer your complaint if needed.
• We will respond whether we agree with your complaint or not.
• If we do not agree or are not responsible for the problem, we will let you know and tell you why.