According to CMS, a complaint may be a grievance or an appeal and is any expression of dissatisfaction with care received by the patient.
A grievance is any complaint or dispute related to the manner in which health care services were given. These may range from minor to major problems. Excluded are disputes related to organization determination, which is handled by appeal. A grievance exists regardless of a request for remedial action.
Examples of grievances may include:
(1) inappropriate behavior of a doctor or provider
(2) unacceptable quality of care given by a provider or hospital
(3) drug error
(4) unnecessary or inappropriate treatment
(5) excessive delay in care
(6) being discharged from a hospital too soon
(7) incomplete or inadequate discharge instructions
(8) claim of abuse
(9) unsafe conditions
(10) unclean conditions
In practice a hospital may call a minor issue that can be easily resolved a complaint and a major issue a grievance. This is not a distinction made by CMS.
A grievance can be filed in writing or orally up to 60 days after the event.
An appeal is submitted when an enrollee is denied a service (plan refuses to cover a service, supply or prescription) AND the enrollee believes that s/he is entitled to receive it.
