Appeals and Grievances

As a member of Select Health Medicare, you have the right to file an appeal and/or grievance.

An appeal is a request you may make for reconsideration of our decision on a service, supply, or drug you have received or requested.
You may file an appeal when you believe the services or supplies should be covered or they should be covered differently than
Select Health Medicare approved or paid them. You also have the opportunity to provide additional information to support an appeal.

A grievance is a complaint that does not involve a decision of payment or coverage. For example, grievances may be filed if you are
unhappy with the quality of care or service you receive from us or from our providers.

A Part D redetermination appeal is a request you make for a reconsideration of our decision on a Part D coverage determination.

How to File an Appeal or Grievance

If you need to file an appeal or grievance, you can submit a form:


Online Appeal Form

Online Grievance Form

By Mail:

Attn: Appeals Dept.
Select Health
P.O. Box 30196
Salt Lake City, UT 84130

picture_as_pdf Appeal Form

picture_as_pdf Formulario de apelación

picture_as_pdf Grievance Form

picture_as_pdf Formulario de agravio

picture_as_pdf Part D Redetermination Form

picture_as_pdf Solicitud de redeterminacion de la denegacion de medicamentos recetados de Medicare


call 844-208-9012 (toll free) (TTY:711)


print 801-442-0762

Appointing a Representative

You may appoint someone to communicate with us on your behalf to request a coverage determination, organization determination, or file a grievance or appeal.

picture_as_pdf CMS Appointment of Representative form

picture_as_pdf Nombramiento de un Representante

Waiver of Liability

An out-of-network provider may become a party to an appeal only if the provider has executed a waiver of liability statement. This form ensures that you, the enrollee, will not be held financially responsible for any charges should the provider lose the appeal.

picture_as_pdf Waiver of Liability Statement

Quality of Care Complaint

A quality-of-care complaint can be filed with Select Health Medicare or the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO). A BFCC-QIO has a group of doctors and other healthcare professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. A BFCC-QIO is an independent organization. It is not connected with our plan.

You should contact the BFCC-QIO in your state in any of these situations:

  • You have a complaint about the quality of care you have received.
  • You think coverage for your hospital stay is ending too soon.
  • You think coverage for your home health care or skilled nursing facility care is ending too soon.
  • Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.







Appeals and Grievances Disclaimer

For information on our Grievance and Appeals Process, please see the section of your Annual Notice of Changes/Evidence of Coverage (EOC) document titled "What to Do If You Have a Problem or Complaint (Coverage Decisions, Appeals, Complaints)". This section of your EOC document explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. The EOC document also explains how to make complaints about quality of care, waiting times, customer service, and other concerns.

To obtain an aggregate number of grievance, appeals, and exceptions filed, for full information on benefits, or to check the status of an appeal or grievance, please call 855-442-9900 (TTY: 711).

You can also submit a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the Medicare Complaint Form.

Visit the Medicare Ombudsman Center to learn how the Office of the Medicare Ombudsman helps you with complaints, grievances, and other requests