What is the difference between an appeal and a grievance?

• A. An appeal is a request to reconsider a denied claim for coverage.
• B. A grievance is a complaint about the quality of care.
• C. An appeal is a request to reconsider a denied claim for coverage; a grievance is a complaint about the quality of care or services, not necessarily related to coverage.
• D. A grievance is a request to review a denial of eligibility for benefits.

Answer: (C)

The difference lies in what is being challenged: coverage decisions versus the care experience. An appeal is the formal request to reconsider a denial of benefits or coverage for a service. A grievance is a complaint about the quality of care or services, or about access and experiences, and it isn’t necessarily tied to whether benefits were denied. For example, if a claim for a procedure is denied, you’d file an appeal to have the coverage decision reviewed. If you’re unhappy with how you were treated or with the quality of care received, you’d file a grievance. This distinction is why the best description covers both: an appeal concerns denial of coverage; a grievance concerns the quality or delivery of care, not just coverage.