Access to quality health care services is crucial for maintaining your well-being, helping prevent and manage diseases. If you’re unsatisfied with your health care, you may want to talk with the individual who performed the care. But if you don’t wish to speak with that person or need more help, you can file a Medicare complaint (aka grievance).
Medicare Complaint vs. Medicare Appeal
A complaint pertains to the quality of care you received or are receiving. For instance, you can submit a complaint if you have an issue calling the plan, or you’re unhappy with how a plan’s staff member treated you.
Meanwhile, you can file an appeal if you have a problem with a plan that’s unwilling to cover a supply, service, or prescription.
When Do You Have the Right to Appeal?
You have the right to appeal if Medicare refuses:
- A request for a health care item, service, supply, or prescription drug that you believe you should get.
- A request for payment of a healthcare item, service, supply, or prescription drug you already received.
- A request to change the amount you have to pay for a healthcare item, service, supply, or prescription drug.
The Appeals Process Has Five Levels
You’ll get a decision at each level of the appeals process. If you disagree with a decision made at any level, you can usually proceed to the next level by following the decision letter’s instructions.
Filing a Complaint Is Your Right
How you file a complaint will depend on the issue. There is some overlap, but the main types of grievances pertain to:
- Durable medical equipment
- Your dialysis or kidney transplant care
- A Medicare doctor, hospital, or provider – which could include:
- Unprofessional conduct
- Unsafe conditions (water damage or fire safety concerns)
- Getting released from the hospital too soon
- Incomplete discharge instructions or arrangements
- The quality of your care
- Unnecessary surgery
- Inappropriate treatment
- If there aren’t enough specialists to meet your needs
- Your health or drug plan
- Drug errors
- Customer service
- Problems with an appeal
- The plan’s notices don’t follow Medicare’s rules
Each Plan Has Its Own Rules
If you’re signed up for a Medicare health or drug plan, each has separate rules for filing a Medicare complaint. If you still need assistance after filing a claim with your plan, call 1-800-MEDICARE (1-800-633-4227).
For other types of Medicare-related grievances, call your State Health Insurance Program (SHIP) for free assistance.
Once you file your complaint, your supplier has to:
- inform you they got your claim and are examining it within 5 calendar days, and
- send you the result and their answer in writing within 14 calendar days.
The Role of a Medicare Agent
Each year, Medicare plans change, and the premiums go up. At Trusted Senior Specialists, we assign an agent to you to make sure you’re in the right program and will be there for you year in and year out. We won’t disappear after we get you signed up. Whether you need to change your coverage, file an appeal, or file a complaint, we’re here to help.
Contact Trusted Senior Specialists
We believe in creating everlasting relationships with our clients. Let us help get you the health care you deserve — call (844) 325-8710 or schedule a video chat through our website.