Appeals and grievances

What is an appeal?

If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

How can I file an appeal?

You may file an Appeal over the telephone, in writing, in person or via email. 

You can:

1. Call Fallon Health's Member Appeals and Grievances Department at: 1-800-333-2535 (TRS 711), Monday through Friday from 8 a.m. to 6 p.m.
2. Send a letter describing your request to:
   Fallon Health
   1 Mercantile St., Ste 400 
   Worcester, MA 01608  
   Attn: Member Appeals and Grievances Department
3. Present your request, in person, Monday through Friday from 8 a.m. to 6 p.m. at: Fallon Health, 1 Mercantile St., Ste 400, Worcester, MA 01608
4. Send an email to: grievance@fallonhealth.org
   For more information, see your Member Handbook, in the section called “How to file complaints, compliments, inquiries, grievances, and appeals."
   
   

What is a grievance?

A grievance is a type of complaint you make about a problem about quality of care, waiting times, customer service or other concerns.

How to file a grievance

When you have a Grievance, our representatives are available to help you. You may discuss your Grievance in person with a representative at our office, or you may call:

• 1-866-473-0471 (TRS 711) 8 a.m.–6 p.m., Monday–Friday
• Fallon’s Member Appeals and Grievances Department at 1-800-333-2535 (TRS 711), Monday through Friday from 8 a.m. to 6 p.m.

If you prefer to send a written Grievance to the Member Appeals and Grievances Department, include all details about the Grievance, any pertinent dates and, if applicable, names of providers from whom you have received your care.
If you want, you may appoint, in writing, an individual (family member, friend, physician/provider, etc.) to act on your behalf.

You can send your Grievance to:
Fallon Health
1 Mercantile St., Ste 400
Worcester, MA 01608
Attn: Member Appeals and Grievances Department

For more information about Grievances, please see your Member Handbook, in the section called “How to file complaints, compliments, inquiries, grievances, and appeals.”

If you need more information or help

• Call : 1-866-473-0471 (TRS 711) 8 a.m.–6 p.m., Monday–Friday
• You can also contact the MassHealth Ombudsman. The MassHealth Ombudsman is an independent office that helps individuals, including their significant others and representatives, address concerns or conflicts that may interfere with their enrollment in MassHealth or their access to MassHealth benefits and services. Find out more at MassHealthChoices.com.