Determinations, Appeals and Grievances

Organization Determinations, Appeals and Grievances

Need to file an Appeal, Grievance, or Complaint regarding any service or other concern? Let us guide you.

  • Organization Determination – A decision made by FirstMedicare Direct about whether a medical service or item requested for you is covered by the plan and the amount, if any, you are required to pay for the item or service.
  • Appeal – A formal request filed with the plan if you disagree with our decision and want to ask us to review and change a coverage decision we have made. (Must be filed no later than 60 calendar days from the date on written decision notice.)
  • Grievance – Any complaint or dispute expressing dissatisfaction with the manner in which FirstMedicare Director or a delegated entity provides health care services, (must be filed no later than 60 calendar days from the date of the event.)

To file an appeal or grievance the first step is to call Member Services. Please call Member Services at 1-844-201-4957. Member Services can also assist members with requests to obtain an aggregate number of grievances, appeals and exceptions filed with the Plan/Part D sponsor.

  • Hours are from 8am-8pm Eastern, 7 days a week during October 1-March 31. During April 1- September 30, hours are Monday through Friday, 8am-8pm Eastern.
  • TTY users should call 711 for assistance.
  • Member Services also has a free language interpreter service available for non-English speakers.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us at the address or fax below. Be sure to describe your complaint or use the link to the appeals and grievance form below.

FirstCarolinaCare Insurance Company
Attention: Appeals and Grievance Department
42 Memorial Drive
Pinehurst, NC 28374

You may fax us at 1-816-313-3061.

The following document links contain detailed information on how to file an appeal, a grievance/complaint or appoint a representative to file the complaint on your behalf and the link to the appeals and grievance form.

Appeals & Grievances Form

Appointing a Representative

For more information or any questions regarding your plan please visit

Choose your county
Choose Member tab at the top
On the left is a list of resources to help answer any questions

Complaints about FirstMedicare Direct can also be submitted directly to Medicare through the following link: