Key points
- An appeal asks your plan to change its decision. External review asks someone outside the plan to decide.
- A complaint to a regulator asks an agency to look at how the plan behaved. It does not replace an appeal.
- A grievance can mean different things: a service complaint in Medicare and Medicaid, but sometimes the word for an appeal.
- Use the word on your notice, because the same word can mean different steps in different programs.
These words are used loosely, and each program uses them its own way. Here is the short version. An appeal asks your plan to reverse itself. External review asks an independent reviewer to decide. A complaint asks an agency to look at how the plan behaved. A grievance is, in some programs, a complaint about service, and in others the plan’s word for an appeal.
What this means
| Word | What it is | Who decides | Starts when |
|---|---|---|---|
| Appeal (internal appeal) | You ask the plan to reconsider a decision about coverage or payment | The plan, by a different reviewer | After a denial |
| Official names for an appeal | Reconsideration or redetermination in Medicare, plan appeal in Medicaid managed care | Varies by program | After a denial |
| External review (independent review) | You ask a reviewer outside the plan to decide | An independent review organization | After the final internal denial, or sooner in an urgent case |
| Complaint to a regulator | You ask an agency to look into the plan’s conduct | The agency | Alongside an appeal; ask the agency about its time limits |
| Grievance | In Medicare and Medicaid managed care, a complaint that is not about a coverage decision; some states and plans use it for an appeal | The plan | Within a time limit set by the program |
| Fair hearing | In Medicaid, a hearing run by the state | A state hearing officer | After a plan appeal in managed care |
How each works
- Appeal. The plan must decide on the clock set for its kind of plan. Under the federal rules for private plans, the reviewer cannot be the person who made the first decision.
- External review. Non-grandfathered private plans must offer it. The reviewer decides the case fresh and is not bound by the plan’s earlier decisions. Under the federal process it is free, and the decision binds the plan.
- Complaint. Complaints about a private employer plan go to the federal Employee Benefits Security Administration (help line 1-866-444-3272); complaints about an insurance company or an insured policy go to the state insurance department. A complaint is a separate track from an appeal. For Medicare, complaints about quality can go to the plan, to the Quality Improvement Organization, or both.
- Grievance. In Medicare Advantage, an appeal challenges a coverage or payment decision, and a grievance is any other complaint, such as rudeness or waiting times. A grievance must be filed within 60 days of the event, and the plan must respond within 30 days. In Medicaid managed care, a grievance can be filed at any time, and the state sets the time to respond, up to 90 days.
What to do
- Read the word on your notice. It tells you which step you are being offered.
- If you want the decision changed, appeal. Follow the instructions on the notice and see how to file an internal appeal.
- If the plan has already given a final denial, ask about external review. Use the external review planner.
- If the problem is how the plan behaved, such as delays, missing notices or ignored requests, file a complaint with the right regulator in parallel. The regulator complaint builder helps.
- If you are in Medicare or Medicaid, use the program’s names: see the five levels of Original Medicare appeal or Medicaid appeals and fair hearings.
- Keep all deadlines separate. A complaint does not stop an appeal clock (check the date on your notice, which controls).
What the plan may say, and what to say back
“We will note your complaint.” Ask: “Is that an appeal of the decision? Please tell me in writing whether you are treating this as an appeal.”
“You can file a grievance.” Ask: “Is that a complaint about service, or the way to appeal this coverage decision?”
The rule
Every non-grandfathered group health plan and insurer must offer external review, either under a state process that meets federal minimum standards or under a federal process. The external decision binds the plan and the claimant, except to the extent other remedies are available under state or federal law. Source: Code of Federal Regulations (CFR) Title 29, section 2590.715-2719(c) and (d).
Watch for
- A Marketplace appeal is not a claim appeal. The Marketplace appeal challenges an eligibility decision made by the Marketplace, such as whether you can buy a plan or how big your tax credit is. Claim denials from a Marketplace plan go through the plan’s appeal and then external review. See Marketplace eligibility appeals.
- Not every denial qualifies for external review. Under the federal process, denials involving medical judgment qualify; a denial that you do not meet the plan’s eligibility requirements does not.
- Medicaid external review is up to the state. It is optional for states, and in a 2023 report by the Office of Inspector General of the United States Department of Health and Human Services using 2019 data, only 14 of the 37 states studied offered it.
- Free is not universal. The federal process is free; a state process may keep a small filing fee if state law authorized it by 18 November 2015.
What next
- Start the first step: how to file an internal appeal.
- Learn the second step: how external review works.
- Learn about regulators: who regulates your plan.
- Go to the topic page, work out whether it is really a denial.