A grievance, or complaint, is different from a request for an organization determination, a request for coverage determination, or a request for an appeal as described in each plan’s Evidence of Coverage. Grievances are for problems related to quality of care, waiting times or the customer service a member receives.
Grievances do not involve problems related to coverage or payment for care, prescription drug benefits, early hospital discharges, or coverage for skilled nursing facility, home health agency or comprehensive outpatient rehabilitation facility services ending too soon.