The Centers for Medicare and Medicaid Services (CMS) released a new online form for providers to submit complaints about Medicare Advantage (MA) plans.
Complaints may be related to appeals, payments, denials, and other plan specific issues, provided they relate to a specific beneficiary. The form requires information about the complainant, beneficiary, provider, MA plan, a complaint summary, and optional date(s) of service, and claim number fields. As the information is submitted directly online, MA plans will not receive the original provider complaint form.
Once submitted, the complaint will be sent to the Health Plan Management System (HPMS) Complaints Tracking Module (CTM). Complaints enter a queue in the CTM, for CMS review and triage before assigning a contract number. Once assigned to a plan, the plan has up to 30 days to respond. Providers will receive an automated email when their complaint is assigned.
To access the form, providers can follow the following instructions or click here. - Select “Medicare” from the top left dropdown menu.
- Select “Health & drug plans” from the navigation menu.
- Select “Report a provider complaint about an MA plan”.
Per CMS providers should first follow – and fully exhaust – the appeals and disputes processes established in their contracts. After completing that process, providers who believe a plan has violated CMS rules or policies directly tied to a beneficiary may submit the information via the form.
CMS confirmed that the following types of issues may be submitted through the complaint form, provided each complaint pertains to a specific beneficiary:
- Communication Delays Affecting Required Timeframes
Instances in which a lack of timely communication from the MA plan causes an issue to fall outside a required timeframe, and the plan subsequently asserts that the appeal window has expired.
- Provider Appeal Complaints
Situations in which a contracted or non‑contracted provider believes an MA plan did not follow the required appeals process, such as failing to inform the provider of the process or failing to respond to an appeal.
Disputes related to the payment amount for an approved service, including partial approvals, downcoding, bundling, or assignment of a lower level of care resulting in reduced payment.
AHCA has long advocated for a provider‑initiated complaint process and encourages providers to use this to clearly illustrate ongoing MA access and care-delivery issues in SNF/PAC settings, thereby strengthening CMS’ ability to identify systemic problems and support meaningful improvements.
Please reach out to AHCA’s Population Health Policy Analyst Rohini Achal or Nisha Hammel, Vice President, Reimbursement Policy & Population Health with any questions.