Grievances, Complaints & Appeals

A grievance is a written or verbal expression of a member’s dissatisfaction with the care or services provided and may be used to request a review of a complaint or inquiry that has not been resolved to the member’s satisfaction. Grievances should be submitted to the member’s assigned health plan online, by phone, or in writing.

A complaint (or inquiry) is a member’s written or verbal request for information or assistance, or an expression of concern about an issue. A complaint can become a grievance. Complaints should be submitted to the member’s assigned health plan online, by phone, or in writing.

An appeal is a written or verbal request to reconsider the initial determination of a denied healthcare service or claim. Appeals can be requested by submitting a written or verbal notification to the members assigned health plan to appeal any decision that the member believes is unfair or unjust.

Members have the right to file a discrimination complaint with the United States Department of Health and Human Services Office of Civil Rights if there is a concern of discrimination based on race, color, national origin, age, disability, or sex electronically through the Office for Civil Rights Complaint Portal or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201. Complaint forms are available at the U.S. Department of Health and Human Services website. Complaints filed with the U.S. Department of Health and Human Services; Office for Civil Rights must be filed within 180 days of the date of the alleged discrimination.