Plan information

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 (updated 4/22/22) 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)

Appointment of a representative

If you want a friend, relative, your doctor or another person to represent you in your healthcare-related affairs, you can give person permission to submit coverage determinations, exceptions and appeals on your behalf. Complete the Appointment of Representative (AOR) form and be sure you and the person who will act on your behalf sign it. You must provide us a copy of the signed form.

An AOR form is valid for 365 days from the date both parties signed the document. Once you submit a valid AOR, the form will be on file with us until it expires. You can ask us to reuse an AOR on file with each new appeal or grievance request. You can also revoke a request for appointment of a representative by completing a revocation form and providing that to us.

Appointment of Representative Form 


Disenrollment

You can end your membership in the WellSense Medicare Advantage plan during certain times of the year, typically during the Annual Enrollment Period (AEP) that runs from Oct. 15 to Dec. 7 or during the Open Enrollment Period (OEP) from Jan. 1 to March 31. In certain circumstances, you may be able to leave the plan at other times of the year, during Special Enrollment Periods (SEP).

During an enrollment period, if you choose to end your membership in our plan, you can enroll in another Medicare plan. If you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must request to be disenrolled from our plan. If you would like to be disenrolled you can make the request by writing to us at:

WellSense Medicare Advantage
ATTN: Enrollment
100 City Square, Suite 200
Charlestown, MA 02129

Most cases of disenrollment are your choice but, in some circumstances, you may be disenrolled involuntarily. There are situations that could require you to leave our plan, such as:

  • Loss of your Part A benefits and/or disenrollment in Part B
  • Failure to pay your plan premium

Disenrollment from our plan is subject to CMS rules. For more information about disenrolling from our plan or your rights and responsibilities, see your Evidence of Coverage.

You can call Member Services at 1-855-833-8128 (TTY: 711) if you have questions about disenrollment. You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) to disenroll.

 

Member services

Contact Member Services at (855) 833-8128 (TTY: 711) Monday through Friday 8 a.m. to 8 p.m. (April 1 through September 30, except holidays) or seven days a week (October 1 through March 31).