Appeals and grievances

What is an appeal?

Have we told you that we will not cover or pay for a medical or pharmacy service? If we make a decision about your coverage and you are not satisfied with it, you can appeal it. 

• An appeal is a formal way of asking us to review and reconsider our decision.
• Your appeal will be handled by different reviewers than those who made the original decision. When we have completed the review, we will give you our decision.
• You need to file an appeal within 60 calendar days of the date listed on the notice of initial coverage decision.

How to appeal a decision about a drug

You or your appointed representative can complete the Request for Redetermination of Medicare Prescription Drug Denial form.

How to appeal a decision about a medical service

You or your appointed representative can contact us in one of the following ways to file an appeal:

• Call Member Services at 855-833-8125 (TTY: 711)
• Fax your appeal letter with your reason for appealing to 617-897-0805
• Send your appeal letter to:
  WellSense Senior Care Options
  Attention: Member Appeals
  100 City Square, Suite 200
  Charlestown, MA 02129

If you disagree with the decision about a medical service, you can make another appeal. To learn more about the appeals process, please see your Evidence of Coverage which has detailed instructions on how to file appeals.

Need help making an appeal?

Listed below are resources you may wish to use if you decide to ask for any kind of exception or appeal a decision:

• You can call Member Services and we will walk you through the process.
• Your doctor can make a request for you.
• You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your representative to ask for an exception or make an appeal. This can be a relative, close friend, or a lawyer. Fill out an Appointing a Representative Form to get started.

You have the option to file an appeal with MassHealth

• Your name
• Your address and phone number
• Your MassHealth ID number or social security number
• Reason for your appeal
• If you would like your hearing to be scheduled as soon as possible
• If you need an interpreter to be provided

Please send your request to:

Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Fax: 617-847-1204

What is a grievance?

A grievance is a way for you to file a formal complaint if you are dissatisfied with any aspect of the quality of care or services you receive from a doctor, staff member, pharmacy, or our plan. You can file a grievance if you disagree with a coverage decision that we made about a medical service or drug, or if you were unhappy with the quality of care received from a doctor or pharmacy. You can also file a grievance if you requested an expedited appeal decision but we reviewed it as a standard appeal.

A grievance will not change the outcome of a coverage decision or a payment dispute, but your expression of dissatisfaction will remain on file with us and allow us to use your concerns to when updating processes and policies.

How to file a grievance

You or your appointed representative can file a grievance in the following ways:

• Call Member Services at 855-833-8125 (TTY: 711)
• Send a fax to 617-897-0805
• Send a letter to:
  WellSense Care Options
  Attention: Member Grievances
  100 City Square, Suite 200
  Charlestown, MA 02129

You can also submit your complaint directly to Medicare. You can either use their online form at Medicare.gov, or you can call 1-800-MEDICARE (1-800-633-4227) to speak with a representative. TTY/TDD users can call 877-486-2048, 24 hours a day, 7 days a week.

Requesting a report of all grievances, appeals, and exceptions

You may request a report from us showing the total number of grievances, appeals, and exceptions filed with our plan. To request this report, please call Member Services.