A grievance is a complaint about how a plan behaved. An appeal is a challenge to what a plan decided. They run on different tracks with different deadlines, and filing the wrong one is how people lose weeks.

An appeal is for a coverage decision: a denied service, a denied drug, a reduction in hours, an amount you think is wrong. It can overturn the decision.

A grievance is for conduct: nobody answered the phone for three days, the directory sent you to four providers who do not take the plan, the authorization sat unprocessed, you were treated rudely, the interpreter you asked for never appeared. It cannot overturn a decision, and it creates a record.

Two reasons the record matters more than it sounds. Plans are measured on grievances, so volume in a category gets internal attention that individual appeals do not. And a documented grievance is frequently the evidence that makes a later complaint to a regulator concrete rather than anecdotal.

In New York: the routing depends on what went wrong, and picking right saves time.

A coverage decision goes to the plan’s internal appeal, then to an external appeal through the Department of Financial Services, decided by a reviewer who does not work for your insurer. On Medicaid it is the plan appeal and then a fair hearing, where the aid continuing deadline of roughly 10 days is what keeps an existing service running.

Conduct, access and network problems are a grievance, and they can go to the plan and to a regulator at the same time. The Department of Financial Services takes them at 800-342-3736; the Attorney General’s Health Care Bureau Helpline at 800-428-9071; for a self-funded employer plan, the US Department of Labor at 866-444-3272.

A network that works for medical care and not for mental health is the case where the two overlap most usefully. That is a grievance about access and a parity issue at the same time, and saying the word parity routes it differently. How parity works.

Whatever the track, the useful version is short, dated and specific: what you asked for, when, who you spoke to, and what happened.

Also called: complaint, plan complaint. Full guide: How to appeal a denial in New York.

More in Glossary of health coverage and billing terms

  • Federally qualified health center — A clinic required to charge by household income rather than by service, which is why it is the cheapest real option for most uninsured New Yorkers.
  • Managed care — A plan that pays a private insurer a fixed amount per member to run your benefits, which is why a network and prior authorization exist at all.
  • Cost-sharing reduction — A discount on the deductible and copays that only attaches to silver marketplace plans, and is invisible when you compare premiums.
  • Prior authorization — Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
  • Network (in-network and out-of-network) — The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.

This page explains how the system works. It is not medical advice. More.