If your concern is
then you may start the complaint process. Please submit the form describing concerns about your own care or complete the form packet if you are submitting a complaint on behalf of a Medicare beneficiary.
After we have received the completed complaint form, you will be assigned a case manager who will keep you updated throughout the entire process. However, please note that federal laws control the way we investigate and respond to your complaint. The law limits the amount of information we are allowed to share with you. Our findings are not allowable in court, and do not directly affect coverage, payment, or billing.
We offer the following free services to address the concerns you might have about the quality or necessity of your care. Each is described in more detail below.
An independent physician (one who does not have a relationship with your healthcare provider or the place where you received care) will review your medical record and determine whether the care you received was similar to what would have been given to you by most healthcare providers. This is called “meeting professionally recognized standards.”
Our decision will be based on the information written in your medical record. We cannot do other kinds of investigation, such as interviews or site visits.
If there is not enough information documented in your medical record that relates to your concern, we will not be able to make a decision one way or the other. If we determine that your care did not meet professionally recognized standards, Qualis Health will work with your healthcare provider to make changes and improve future care.
For more information about Medicare's medical record review process, please see:
If your case appears to be a good candidate for mediation or facilitated resolution, we may refer both you and your healthcare provider to these services instead of, or in addition to, the medical record review.
Mediation and facilitated resolution provide an impartial, effective means to resolve communication problems.
The goal of these methods is to resolve the issue to both parties’ satisfaction. Participation is voluntary.
Medicare's medical review process focuses on concerns related to the "quality or necessity of medical care."
Examples include preventable situations in which the care caused you harm, or put you in a situation where you could have been harmed, such as:
Medicare's complaint-resolution process does not investigate issues related to unprofessional or impolite behavior, housekeeping, or the temperature of your room or food. For help with these concerns, please review our list of suggested resources.
If you would like help deciding whether our complaint-resolution services are appropriate for your case, please call 1-800-MEDICARE (1-800-633-4227, or TTY/TTD 1-877-486-2048 for the hearing and speech impaired). If your care was provided in Idaho or Washington, you will be connected with our helpline.