Appeals and Grievances Terminology
A quick-reference glossary for interpreting conversations about coverage disputes, service complaints, and review rights.
An appeal generally asks for review of a coverage or payment decision. A grievance generally reports dissatisfaction about care, service, or another issue outside the applicable appeal process. One situation may involve both, and the formal classification depends on the program.
Requests, complaints, and representatives
- Appeal: A request to review a decision denying, reducing, ending, or otherwise limiting coverage or payment under applicable rules.
- Grievance: A complaint about care, service, or another matter handled through the program’s complaint process rather than its coverage appeal process.
- Quality-of-care complaint: A concern about the safety or quality of healthcare received.
- Authorized representative: A person permitted to act for a member under the applicable process.
- Appointment of representative: Documentation or another accepted process establishing a representative’s authority.
- Supporting evidence: Information submitted to explain or substantiate a request for review.
- Denial notice: Written information explaining an unfavorable decision and applicable review rights.
Types and levels of review
- Standard appeal: An appeal reviewed within the usual applicable timeframe.
- Expedited appeal: A faster appeal available when defined urgency criteria are met.
- Reconsideration: A review stage whose meaning and reviewing organization depend on the program and appeal level.
- Redetermination: A review term used in certain appeal processes, including Medicare drug plan appeals; it also has a separate eligibility-review meaning.
- Independent review: Review conducted by an entity separate from the original decision-maker under the applicable process.
- State fair hearing: A formal state administrative review process available for specified Medicaid or other benefit disputes.
- Fast discharge appeal: An expedited process for challenging the ending of certain Medicare-covered facility or care services.
- Continuation of benefits pending appeal: Ongoing provision of specified benefits while a qualifying appeal is considered, subject to request, timing, and other requirements; repayment obligations may apply.
Outcomes and deadlines
- Filing deadline: The latest time to submit a request under the applicable rules.
- Acknowledgment: Confirmation that a complaint or appeal has been received.
- Favorable decision: A decision granting the requested relief in whole or in part.
- Upheld decision: A decision leaving the earlier determination in place.
- Reversal: A decision changing an earlier determination.
- Decision notice: A communication explaining the outcome and any further review rights.
- Withdrawal: Ending a request at the request of the person entitled to do so.
Appeal levels, complaint procedures, deadlines, expedited review criteria, and continued-benefit rights vary across Original Medicare, Medicare Advantage, Part D, Medicaid, and other coverage. The specific notice and current program rules determine the next steps. Interpreters should preserve decision dates, deadlines, and rights accurately without selecting a legal strategy or promising an outcome.