Medicare Advantage Complaints

All Medicare Advantage plans have a customer service office you can call for help. Look on your membership card for the phone number. Medicare has different procedures for different kinds of problems. For help, you can always call HICAP at 1-800-434-0222.

Topics on this page

• If you have a problem with a bill
• If your plan does not cover a drug you need
• If your plan denies, delays, or stops treatment
• If your hospital, home health, nursing home, or rehab care is ending
• If you have a customer service problem
• More information and help with Medicare

If you have a problem with a bill

When you submit a bill for payment, your plan has 60 days to review it.

• If your plan says it will not pay your bill, you have 60 days to file an appeal.
• The plan has 60 days to respond to your appeal.
• If the plan still says no, call HICAP at 1-800-434-0222.

If your plan does not cover a drug you need

• You or your doctor can call your plan and ask it to cover the drug.
• If you need the drug urgently, your doctor can ask for an expedited or fast review.
• If your review is expedited, the plan must call you with a decision in 24 hours. In other cases, the plan has 72 hours to reply.

If your plan denies, delays, or stops treatment

• File an appeal with your plan. Your plan must reply in seven days.
• If your problem is urgent, file an expedited appeal. Your plan must reply in 72 hours.
• Ask a doctor to help you. He must show that it would be seriously harmful to deny or delay your care. The doctor does not have to be part of your plan.

If your hospital, home health, nursing home, or rehab care is ending

• If these services are ending too soon, call Lumetra at 1-800-841-1602. The federal government contracts with Lumetra to help Medicare members file s and resolve disputes.

If you have a customer service problem

You can file a grievance if you are unhappy with the way you are treated or how long you have to wait for appointments.

• Ask your plan to send you a grievance form. Fill out the form and mail it back.
• Your plan must take action within 30 days after it gets your form.
• If your plan still will not help or does not reply within the time limit, you can call Lumetra at 1-800-841-1602.

More information and help with Medicare

• The CalMedicare website tells you more about dealing with problems with a Medicare Advantage plan.
• Call HICAP at 1-800-434-0222.
• HICAP provides free help for Medicare members.

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