Appeals and grievances

Appeals

If we told you that we will not cover or pay for a medical or pharmacy service and you do not agree with our decision, you can appeal it. An appeal is a formal way of asking us to review and reconsider our decision.

When you file an appeal, we review our original decision to see if we were following the rules properly. Different reviewers than those who made the original decision will handle your appeal. 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 the initial coverage decision.

To appeal a decision about a drug claim
You or your appointed representative can complete the Request for Redetermination of Medicare Prescription Drug Denial Form and submit it to us.

To appeal a decision about medical services
You or your appointed representative can contact us in one of the following ways to file an appeal:

  • Call Member Services at 1-855-833-8128 (TTY: 711)
  • Fax your appeal letter with your reason for appealing to 617-897-0805
  • Send your appeal letter to:
    WellSense Medicare Advantage
    Attn: Member Appeals
    100 City Square
    Suite 200
    Charlestown, MA 02129

If you disagree with the appeal decision, 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.

If you need help making an appeal, you have options.

  • Call Member Services at 1-855-833-8128 (TTY 711) and our agents can walk you through the appeal process
  • Your doctor can make a request for you
  • Ask someone to act on your behalf

Grievances

If you are dissatisfied with your experience with a doctor, pharmacy or staff member of our plan or if you disagree with a decision we have made, you can file 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 we made about a medical service or drug. You can 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 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 1-855-833-8128 (TTY: 711)
  • Send a fax to 617-897-0805
  • Send a letter to:
    WellSense Medicare Advantage
    Attn: Member Grievances
    100 City Square, Suite 200
    Charlestown, MA 02129

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

Aggregate number of appeals, grievances and exceptions
You can request the aggregate number of appeals, grievances and exceptions by calling Member Services at 1-855-833-8128 (TTY: 711)