Grievance (complaint)
The Centers for Medicare and Medicaid Services (CMS) defines grievances as a type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of care. This doesn’t involve coverage or payment disputes. You or your appointed representative have a right to file a grievance by expressing your dissatisfaction."
How to file a grievance
The deadline for making a grievance is 60 calendar days from the time you had the problem you want to complain about.
- Usually, the first step is to contact the Customer Care team by phone, we will try to resolve your grievance over the phone.
- If you don’t want to call (or you called and weren’t satisfied), you can put your grievance in writing and send it to us. If you put your grievance in writing, we’ll respond to you in writing. Send a message by logging into your member portal, or write us at:
Priority Health Medicare Grievances
1231 East Beltline NE, MS 1150
Grand Rapids, MI 49525
You can also deliver it in person, or fax it to us at 616.975.8827
You may request an expedited grievance whenever we extend the time frame to make an organization or coverage determination, extend the time frame to make a decision for a reconsideration or redetermination, deny your request for an expedited appeal, or deny your request for an expedited organization determination.
When you’ll hear from us
- We attempt to resolve concerns during the first point of contact. Most grievances are answered within 30 calendar days from the date of receipt of your grievance. We may extend the time frame by up to 14 calendar days if you ask for an extension or if we need additional information and delay our response in your best interest.
- For expedited grievances, we respond verbally within 24 hours if received orally. If the expedited grievance is received in a written format, we will respond verbally within 24 hours AND in writing within three (3) calendar days after the verbal notification.
Other options to file a grievance
- In addition to filing a Quality-of-Care grievance to us, you can file your grievance directly to the Quality Improvement Organization. This is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. Contact information can be found in Chapter 2 of your plan’s Evidence of Coverage.
- You can submit a grievance directly to Medicare, by going to www.Medicare.gov/my/medicare-complaint. You can also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users call 1-877-486-2048.
Appointment of Representative
If you want someone else, like a family member or friend, to act on your behalf, you can sign a form that makes the person your official “authorized representative.” Learn how.