Grievance

A grievance is a formal complaint you file with your health insurance company about any aspect of the plan or its services that does not involve a denial of benefits. Grievances address problems with service quality, access to care, billing practices, or how your plan is being administered — not coverage decisions (which are handled through the appeals process).

Common reasons to file a grievance:

• Difficulty getting timely appointments with in-network providers
• Rude or unprofessional treatment from plan staff or contractors
• Billing errors or confusion about your Explanation of Benefits
• Failure to receive required notices or communications
• Problems accessing care management programs or services
• Concerns about wait times at network facilities

The grievance process is separate from an appeal. If your insurer denies a claim, prior authorization request, or coverage for a service, that’s handled through the appeals process. If you’re unhappy with how the plan operates or how you were treated — but not with a specific coverage decision — that’s a grievance.

Insurers are required to acknowledge grievances within a set timeframe and provide a resolution. If you’re unsatisfied with the outcome, you can escalate to your state insurance department.