Glossary
Grievance
In one sentence
A complaint about anything other than the coverage decision itself. Filing one does not challenge a denial, and filing one instead of an appeal is a common and expensive mistake.
Also written as Complaint.
What grievance actually means
A grievance is how you tell a plan that something was handled badly. Rudeness, a phone line nobody answers, a pharmacy that was not where the directory said it was. It is a real route and it is worth using when it fits.
It is not, however, how you get a decision changed. The definition draws the line by exclusion: a grievance is dissatisfaction about any matter that is not an adverse benefit determination. If what you want is the drug, the filing you need is an appeal, and a grievance filed in its place does not stop your appeal deadline from running.
One thing does sit on the grievance side that people expect to find on the appeal side: if the plan gives itself extra time to decide your authorization, disputing that extension is a grievance.
The text it comes from
This is the wording the definition rests on. Where it decides anything for you, read the section rather than our summary of it.
The definition works by exclusion. "Grievance means an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee's rights regardless of whether remedial action is requested." The regulation adds that "Grievance includes an enrollee's right to dispute an extension of time proposed by the MCO, PIHP or PAHP to make an authorization decision."
42 CFR §438.400(b), Electronic Code of Federal Regulations, effective August 2026 · source
Where this comes from
- 42 CFR §438.400(b), Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-42/part-438/section-438.400
Where this comes up
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page says what a published rule means by a word. Which rulebook governs you depends on your plan, and your own notice and plan documents govern your case.