Health plan complaints and grievances: where to file

Updated 2026-10-14 · Reviewed for accuracy by the EKO Labs team. Educational only; not medical advice.

Most problems with a health plan, a pharmacy or a doctor can be fixed with one phone call. When they are not, U.S. law gives you formal ways to complain, and the right path depends on what went wrong and who it was. This guide explains the difference between a complaint (grievance) and an appeal, how grievances work in Medicare health and drug plans, where to report problems with other insurance, pharmacies, doctors and privacy, and how to keep a good record. It is general information, not legal or medical advice.

Complaint (grievance) or appeal?

HealthCare.gov defines a grievance as a complaint that you communicate to your health insurer or plan. It is different from an appeal:

• File a complaint (grievance) when the problem is the quality of the care you got or how you were treated: long waits, rude or unhelpful customer service, trouble reaching a specialist, a pharmacy that keeps getting your order wrong, or a plan that handled your appeal badly.
• File an appeal when the plan refused to cover a service, supply or prescription, or you got a bill for a claim you already submitted. Appeals have their own deadlines and steps; see our guide on prior authorization and appeals.
• If you are not sure, say so. Medicare plans must promptly decide and tell you whether your complaint will be handled as a grievance or as an appeal (42 CFR 422.564(b) and 423.564(b)).

Grievances in Medicare health and drug plans

Every Medicare Advantage plan and every Medicare drug plan (Part D) must have a process for hearing and resolving grievances in a timely way (42 CFR 422.564 and 423.564). The main rules:

• How: you can file by phone or in writing. The plan's contact details are usually on your membership card and in your plan materials.
• Deadline to file: no later than 60 days after the event or incident that the grievance is about.
• Deadline for the plan: the plan must tell you its decision as quickly as your health requires, and no later than 30 days after it receives your grievance. It can extend this by up to 14 days if you ask, or if it needs more information and the delay is in your interest; then it must tell you in writing why.
• Fast (24-hour) grievances: the plan must answer within 24 hours if you complain because it refused to speed up (expedite) a coverage decision or appeal. For drug plans this applies when you have not yet bought or received the drug in dispute; for Medicare Advantage it also applies when the plan decided to take extra time on a coverage decision or appeal.
• Written answers: a grievance you send in writing gets a written answer. If you complain by phone, the answer may be by phone unless you ask for it in writing. Any grievance about the quality of care must be answered in writing and must explain your right to complain to the Quality Improvement Organization.

Medicare.gov also offers an online Medicare Complaint Form for problems with your Medicare health or drug plan, such as customer service issues, problems getting to a specialist or a problem with an appeal.

Quality-of-care problems in Medicare

If you have Medicare and the problem is the quality of medical care, such as a drug error, being sent home from the hospital without clear instructions, or not getting treatment after abnormal test results, you can contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for your state. Medicare.gov says the BFCC-QIO is run for Medicare by Commence Health or Acentra, depending on where you live. For quality-of-care problems you can file a grievance with your plan, a written complaint with the QIO, or both (42 CFR 423.564(c)).

Other kinds of complaints and where they go

• A doctor or other licensed clinician (licensing questions, unprofessional conduct): your state medical board, or the state licensing board for that profession.
• A pharmacy or pharmacist (for example, repeated dispensing errors or unprofessional conduct): your state board of pharmacy. If you think a mistake has hurt you, get medical help first.
• Unsafe conditions or improper care in a hospital, nursing home or other facility: your State Survey Agency, which is usually part of the state health department. 1-800-MEDICARE can give you its contact information.
• A side effect, a medication error or a problem with a medicine's quality: you can report it to FDA's MedWatch program; see our guide on reporting a side effect to the FDA.
• Your health information privacy (HIPAAHIPAA the U.S. law that protects the privacy of your health information.) or discrimination by a health care provider: the U.S. Department of Health and Human Services Office for Civil Rights (OCR). A HIPAA complaint must be in writing (paper or online) and filed within 180 days of when you knew or should have known about the problem, unless OCR waives the limit for good cause (45 CFR 160.306).
• Insurance you buy yourself, including Marketplace plans: start with the insurer, then your state department of insurance. For Marketplace questions you can also call the Marketplace Call Center at 1-800-318-2596.
• Coverage through a job: follow the complaint steps in your summary plan description. The U.S. Department of Labor's Employee Benefits Security Administration (EBSA) has Benefits Advisors who answer questions about job-based health plans (askebsa.dol.gov). Many insured employer plans are also overseen by the state department of insurance.

Free help

• 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048), 24 hours a day, 7 days a week except some federal holidays.
• Your State Health Insurance Assistance Program (SHIP) gives free, personal counseling to people with Medicare (shiphelp.org).
• The Medicare Beneficiary Ombudsman, created by Congress in 2003, helps with Medicare complaints, grievances, appeals and requests for information.
• You can ask a family member or friend to help, and in Medicare you can appoint them as your representative. Medicare.gov says you can also file many complaints anonymously, depending on where you file.

How to write a complaint that gets results

• Write down dates, times, names and what was said, as soon as possible.
• Keep copies of letters, bills, receipts, pharmacy labels and screenshots.
• Say clearly what happened, why it is a problem and what you want (for example, a correction, an explanation or a change in how your case is handled).
• Ask for a reference or case number and for the answer in writing.
• Note the deadlines: 60 days for a Medicare plan grievance and 180 days for a HIPAA complaint to OCR. Other agencies and plans may have their own time limits.
• Do not stop or change a prescribed medicine because of a dispute without talking to your doctor or pharmacist.

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Sources: HealthCare.gov glossary, Grievance, and How to appeal an insurance company decision; Medicare.gov, Filing a complaint; CMS, Medicare Beneficiary Ombudsman; 42 CFR 422.564 and 423.564 (grievance procedures for Medicare Advantage and Part D plans); 45 CFR 160.306 (complaints to the Secretary, HIPAA); HHS Office for Civil Rights, Filing with OCR; U.S. Department of Labor, Ask EBSA. Consulted October 2026 via the eCFR. This guide is general information, not legal or medical advice.