A Healthy CollaborationSM

Grievance Policy

Find information and contacts to help with Medicare appeals and coverage determination.

Member Grievances

Who can file a Grievance?

  • A member, including the member’s authorized representative,
  • A member’s physician, an ancillary provider or a hospital representing the member, or
  • A legal representative of the deceased’s estate.

What is a Grievance?

A grievance is dissatisfaction with any aspect of the health plan that does not involve an organizational determination - the approval or denial of services - by the health Plan.

When can a Grievance be filed?

A member may file a grievance at any time. The grievance may be verbal or written.

Expedited Grievance

A member may request a fast review or expedited grievance if he or she disagrees with the health plan’s decision not to process the request for an expedited organization determination or an expedited reconsideration.

With whom can I file a Grievance?

A grievance may be filed with ay of the following organizations:

  • Centers for Medicare and Medicaid Services (CMS),
  • The Social Security Administration (SSA),
  • The Health Plan.

All employees and affiliates of the health plan are required to know where to direct member grievances.

Why file a Grievance?

A grievance may be filed anytime a member is dissatisfied with any aspect of the health plan.

How to File a Grievance:

If you have a grievance, we encourage you to first call a Personal Service Specialist at Member Services. We will try to resolve any complaint that you might have over the phone.

If you wish to send a formal written grievance, mail the grievance to:

4888 Loop Central Dr,. Suite 700
Houston, TX 77081

Be sure to include the following:

  • Full name
  • Address
  • ID number
  • Signature
  • Date
  • Summary of the problem
  • Statement of action you are requesting

For pharmacy related grievances, you can

Call 1-877-864-3388 (8 – 5 pm CST, Monday – Friday), 1-866-338-4681 TTY/TDD (8 – 5 pm CST, Monday – Friday), or

Fax the above referenced document to 866-553-0396.

For more information about our Exceptions, Appeals & Grievances policies and procedures please contact Member Services.

Today's Health
1-866-338-4681 (TTY/TDD)

Hours of Operation: (November 15, 2021 to March 2, 2022)
Monday - Sunday 8:00 AM to 8:00 PM local time.

Hours of Operation: (Beginning March 3, 2022)
Monday - Friday 8:00 AM to 5:00 PM local time.

M0018_H8742webr4_1208_CMS (1/2009) Last updated: 1/1/2022

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