How To File A Medicare Complaint Or Appeal A Decision

Navigating the Medicare system can be overwhelming, especially when a service is denied, a bill seems incorrect, or the quality of care does not meet expectations. Fortunately, Medicare provides structured processes for filing complaints (grievances) and appeals that empower beneficiaries to challenge decisions or express concerns.

In this comprehensive guide, we will walk you through how to file a Medicare complaint or appeal a decision, explain the key differences between the two, and explore the detailed steps involved in each process. Whether you’re enrolled in Original Medicare, Medicare Advantage, or Part D, this article will equip you with the knowledge you need to advocate for your health care rights.

Understanding the Basics: Complaint vs. Appeal

What is a Medicare Complaint (Grievance)?

A Medicare complaint, also called a grievance, is a formal way to express dissatisfaction with the quality of care, service delivery, or customer service—not a disagreement with a coverage or payment decision.

Common reasons for filing a grievance include:

Rude behavior by staff
Long wait times for appointments or services
Cleanliness or safety concerns at a facility
Delays in getting prescriptions filled
Difficulty contacting a provider or plan representative

What is a Medicare Appeal?

A Medicare appeal is the process for disputing a coverage, payment, or service denial made by Medicare or a Medicare Advantage/Part D plan. You can file an appeal if:

Medicare denies coverage for a health service, item, or drug
Medicare does not pay for a claim
You believe Medicare should continue paying for a service
Your plan discontinues a covered service or medication

Types of Medicare Coverage Affected

Before filing, it’s important to identify what type of Medicare coverage you have:

Original Medicare (Part A and Part B) Appeals go directly through Medicare and its contractors.
Medicare Advantage (Part C) Appeals and complaints are handled by your Medicare Advantage plan first.
Medicare Prescription Drug Plan (Part D) Complaints and appeals go through the Part D plan provider.

Understanding your plan type determines the correct procedure to follow.

Section 1: How to File a Medicare Complaint (Grievance)

Step 1: Identify the Issue

Complaints are typically about the quality of service or administrative issues and not about coverage or denials. Common grievances include:

Poor treatment by office or plan staff
Excessive paperwork or delays
Denied access to interpreters or accessible materials
Incorrect processing of enrollment or disenrollment

Step 2: File with the Right Entity

Depending on your Medicare plan type, you should submit your complaint to:

Original Medicare: Contact 1-800-MEDICARE (1-800-633-4227)
Medicare Advantage or Part D Plans: File directly with the private plan provider
Quality of care issues: Contact your state’s Quality Improvement Organization (QIO)

Step 3: Submit the Grievance in Writing or by Phone

You have the right to file a grievance within 60 days of the event.

Call your plan or Medicare directly
Or submit a written complaint including:
- Your name, Medicare number, contact information
- Description of the issue
- Date and location of the incident

If filing with a Medicare Advantage or Part D plan, they are required to respond within 30 days (or 24 hours for expedited cases related to prescriptions).

Step 4: Follow Up

After filing, ensure you:

Keep a copy of your submission
Record the date and time you filed
Follow up if you don’t receive a timely response

Section 2: How to File a Medicare Appeal

Appeals are more structured and time-sensitive than complaints. Below are the detailed steps depending on your plan type.

Appealing a Decision Under Original Medicare (Part A or Part B)

Step 1: Review Your Medicare Summary Notice (MSN)

You receive an MSN every 3 months listing services and charges. Look for services marked “not covered” or “denied.”

You have 120 days from the date you receive the MSN to file an appeal.

Step 2: Complete the Redetermination Request

Use the Redetermination Request Form (CMS-20027) or write a letter including:

Your name and Medicare number
Description of the item/service
The reason you believe it should be covered
Any supporting medical records or provider notes

Send your appeal to the Medicare contractor’s address on the MSN.

Step 3: Wait for a Response

You will receive a decision within 60 days
If denied, you can proceed to the next level: Reconsideration by a Qualified Independent Contractor (QIC)

Appealing a Decision Under Medicare Advantage (Part C)

Step 1: Request an Organization Determination

If your plan refuses to cover a service, request a coverage decision in writing or by phone. The plan must respond within:

14 days for standard cases
72 hours for expedited cases (if delay could harm health)

Step 2: File an Appeal (Reconsideration)

If the decision is unfavorable:

File a written request for reconsideration within 60 days
Include your plan ID, service/item, and reason for appeal
Attach medical records or letters from your doctor

Plans must decide within 30 days (services) or 7 days (prescription drugs).

If denied again, your appeal goes to an Independent Review Entity (IRE).

Appealing a Medicare Part D Drug Denial

Step 1: Request a Coverage Determination

Ask your plan to explain why a drug is not covered. You may also request:

A formulary exception
A tiering exception
An expedited review

Step 2: File an Appeal

If unsatisfied:

File a written appeal within 60 days
Include your doctor’s letter explaining medical necessity
Request an expedited appeal if applicable

If denied again, you may proceed through five levels of appeal—similar to other Medicare appeal processes.

Five Levels of Medicare Appeals

No matter your coverage type, there are five levels of appeals available if the decision continues to be unfavorable:

Redetermination by the plan or Medicare contractor
Reconsideration by an independent review entity (QIC)
Administrative Law Judge (ALJ) hearing
Medicare Appeals Council review
Federal district court lawsuit

Each level has specific deadlines, documentation requirements, and monetary thresholds.

Section 3: Special Considerations for Expedited Appeals

When Can You Request an Expedited Appeal?

You may request an expedited decision if:

Delayed care could seriously jeopardize your health, life, or ability to regain function

Common examples include:

Discharge from a hospital or skilled nursing facility
Refusal to approve urgently needed tests or medication

Filing an Expedited Appeal

File immediately with your plan or contact the QIO
The QIO must issue a decision within 72 hours
If denied, you may continue to the next appeal level

Section 4: Where to Get Help with Medicare Appeals and Complaints

1-800-MEDICARE: For help filing complaints or understanding notices
State Health Insurance Assistance Program (SHIP): Offers free counseling and appeal assistance
Quality Improvement Organizations (QIOs): For care quality issues
Medicare Rights Center: A nonprofit that provides consumer support
Medicare.gov: To download appeal forms and track timelines

Section 5: Tips for a Successful Appeal or Complaint

Keep detailed records: Maintain all letters, notices, and documents.
Meet deadlines: Appeals must be filed within strict timeframes.
Use supporting documentation: Include doctor’s letters, test results, or other medical evidence.
Follow up: Don’t assume silence means resolution.
Get help: Use SHIP counselors or legal help if needed.

Frequently Asked Questions (FAQs)

How to File a Medicare Complaint or Appeal a Decision

1. What is the difference between a Medicare complaint and a Medicare appeal?

A Medicare complaint, also known as a grievance, is a formal expression of dissatisfaction with service quality, wait times, facilities, or plan behavior. A Medicare appeal, on the other hand, is a request to review and reverse a denial of coverage or payment for medical services, equipment, or prescriptions.

2. When should I file a Medicare complaint?

You should file a complaint when:

You experience rude behavior from medical staff or plan representatives
Your plan delays services or responses
Your facility is unsafe or unclean
You face language or accessibility issues
You believe customer service is unreasonably poor

Complaints must generally be filed within 60 days of the issue.

3. When should I file a Medicare appeal?

You should file an appeal if:

Medicare or your plan denies payment for a service or item
Coverage is refused for a test, treatment, or prescription
A hospital or nursing facility discharges you too soon
Your plan stops covering a drug or treatment you believe is necessary

Appeals are time-sensitive, with deadlines ranging from 60 to 120 days after the decision notice.

4. How do I file a complaint under Original Medicare (Part A or B)?

To file a complaint under Original Medicare:

Call 1-800-MEDICARE (1-800-633-4227)
Submit a written grievance by mail
If the complaint involves quality of care, contact your state’s Quality Improvement Organization (QIO)

5. How do I file a complaint with a Medicare Advantage or Part D plan?

Contact your plan directly using the number or address on your membership card. You can file by:

Phone
Mail
Online (depending on the plan)

Plans must respond within 30 days, or 24 hours for expedited drug complaints.

6. How do I appeal a denial in Original Medicare?

You must file a redetermination request within 120 days of receiving your Medicare Summary Notice (MSN):

Use Form CMS-20027 or write a letter
Include your name, Medicare number, the denied service/item, and reason for appeal
Send it to the Medicare contractor listed on your MSN

A decision will typically be made within 60 days.

7. How do I appeal a denial in Medicare Advantage (Part C)?

If your plan denies a service:

Request a coverage determination or decision
If denied, submit a Level 1 appeal (reconsideration) within 60 days
Include supporting medical documentation
If denied again, the appeal moves to an Independent Review Entity (IRE)

8. How do I appeal a Part D prescription drug denial?

Request a coverage determination from your Part D plan
If denied, submit a Level 1 appeal
Provide a statement from your doctor explaining medical necessity
File within 60 days of the denial notice
You may also request a tiering exception or formulary exception

9. What happens after I file a Medicare appeal?

The outcome depends on your appeal level:

If approved, you may receive coverage or reimbursement
If denied, you can escalate to the next appeal level, including:
- Reconsideration
- Administrative Law Judge (ALJ) hearing
- Medicare Appeals Council review
- Federal District Court

10. Can I request a faster (expedited) appeal decision?

Yes. You can request an expedited appeal if waiting for a standard review could:

Seriously jeopardize your life or health
Compromise your ability to regain maximum function

Expedited decisions are typically made within 72 hours.

11. Can someone help me file a complaint or appeal?

Yes. You can get free help from:

Your State Health Insurance Assistance Program (SHIP)
A Medicare counselor
A family member or legal representative (with written permission)
1-800-MEDICARE for guidance on the correct process

12. What documentation do I need for an appeal?

You should include:

Your Medicare or plan ID number
A copy of the denial notice
A statement explaining why you disagree
Doctor’s notes, lab results, or other medical records that support your case
Any previously submitted claim forms

13. Can I appeal if Medicare stops paying for a service I’m still receiving?

Yes. This often applies to home health care, hospice, or nursing facility stays. You will receive a notice of termination with instructions on how to appeal. If you appeal before services end, Medicare will continue to cover care until a decision is made.

14. What is a Medicare Summary Notice (MSN)?

The MSN is a quarterly statement from Medicare listing all services billed on your behalf. It includes:

Charges submitted
What Medicare paid
What you may owe
Denied services (marked as “not covered”)

This document is the trigger for an Original Medicare appeal if a denial occurs.

15. What is the Independent Review Entity (IRE)?

The IRE is a neutral, third-party organization contracted by Medicare to review appeals at Level 2 if your plan denies the initial reconsideration request. The IRE has authority to overturn or uphold the denial.

16. How long does the entire Medicare appeal process take?

Timelines vary depending on the level and type:

Redetermination: 60 days
Reconsideration by IRE: 60 days
Administrative Law Judge (ALJ) hearing: Several months
Appeals Council review: A few months
Federal Court: May take a year or more

You will be notified of your rights at each level.

17. Can I continue receiving services during an appeal?

In certain cases (e.g., hospital discharge or nursing home termination), if you file an expedited appeal before services end, Medicare may continue to cover your care until a decision is made.

18. What is a Quality Improvement Organization (QIO)?

A QIO is a contractor for Medicare that reviews complaints related to:

Quality of care
Premature discharges
Hospital/Skilled Nursing Facility (SNF) coverage decisions

They are the correct contact for urgent complaints involving care or discharge.

19. What if I miss the appeal or complaint deadline?

If you miss a deadline, you may lose your right to appeal or complain. However, in some cases, you can ask for a “good cause extension”. You’ll need to explain the reason (e.g., illness, confusion, lost mail).

20. Where can I get official Medicare forms and information?

You can access all necessary forms and information at:

Medicare.gov
By calling 1-800-MEDICARE (1-800-633-4227)
Through your local SHIP office
Directly from your plan provider’s website

Conclusion

Medicare beneficiaries have the right to challenge coverage decisions and report concerns about their care. Whether you are dealing with a denied service, unexpected bill, or poor experience with a provider, knowing how to file a Medicare complaint or appeal a decision is crucial to protecting your health and financial well-being.

The process may seem complex, but with clear information and the right support, you can take confident action. Remember, Medicare works best when its beneficiaries understand their rights and take steps to ensure fair treatment.