Coverage decisions, appeals, and grievances
What to do if you have problems or concerns
Fallon Health is dedicated to providing members with comprehensive health care coverage. However, if you have concerns or problems related to your coverage or care, you have the right to make formal complaints to Fallon Health. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.
Coverage decisions, including exceptions
What is a coverage decision?
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make coverage decisions whenever we decide what is covered for you and how much we pay. An exception is a special request for the plan to cover a drug or remove restrictions from a drug. A request for coverage for Part C services is called an organization determination.
In some cases, we might decide a service or drug is not covered or is no longer covered. If you disagree with this coverage decision, you can make an appeal.
Who can ask for a coverage decision?
Your doctor or other prescriber can ask for coverage decisions. You or your authorized representative can also contact us and ask for a coverage decision if your doctor or other prescriber is unsure whether we will cover a particular medical service or drug.
In other words, if you want to know if we will cover a service or drug before you receive it, you or your representative can ask us to make a coverage decision for you. If you are requesting an exception, your doctor or other prescriber must give us a statement that explains the medical reason for requesting an exception. You may appoint an individual to act as your representative to request a coverage decision for you by filling out an Appointment of Representative form (pdf). You do not need to fill out this form for your provider to make the request.
How to ask for a coverage decision
Coverage decisions for medical care
You can call, write, or fax our plan to make a request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.
Fallon Health
1 Mercantile St., Ste 400
Worcester, MA 01608
Toll-free: 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week).
Fax: 1-508-368-9700 for regular coverage decisions; 1-508-368-9133 for fast coverage decisions.
Coverage decisions for Part D prescription drugs
You can call, write, or fax our plan to make a request for us to authorize or provide coverage for the drug you want. You, your doctor, or your representative can do this. You may also request a Part D coverage decision (also called a coverage determination) using our online form.
OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Toll-free: 1-844-657-0494 (TRS 711), 24 hours a day, seven days a week.
Fax: 1-844-403-1028
Member appeals
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.
Who can file an appeal?
An appeal may be filed by any of the following:
- You
- Someone else on your behalf
- Your doctor (or other prescriber)
You may appoint an individual to act as your representative to file an appeal for you by filling out an Appointment of Representative form (pdf). You do not need to fill out this form for your provider to make the request.
HOW TO FILE AN APPEAL ABOUT COVERED MEDICARE MEDICAL BENEFITS OR PART B DRUGS
- To start an appeal you, your doctor (or other prescriber), or your representative must contact us.
- If you are asking for a standard appeal, make your standard appeal in writing by submitting a signed request. You may send your written appeal to us at Fallon Health, Member Appeals and Grievances, 1 Mercantile St., Ste 400, Worcester, MA 01608. You may also ask for an appeal by calling us at 1-800-333-2535, ext. 69950 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. or by emailing us at grievance@fallonhealth.org.
- If you are asking for a fast appeal, you can fax us at 1-508-755-7393 or call us at 1-800-333-2535, ext. 69950 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. Fast appeals can be requested and are processed 24 hours a day, 7 days a week by leaving a voice message at this number.
- If you have someone appealing our decision for you other than your doctor (or other prescriber), your appeal must include an Appointment of Representative form (pdf) authorizing this person to represent you. While we can accept an appeal request without the form, we cannot complete our review until we receive it. If we do not receive the form within the applicable time.
You may also use Medicare's complaint form that is available online at Medicare.gov. (This link will take you away from the Fallon Medicare Plus website.)
When can an appeal be filed?
You may file an appeal within 60 calendar days of the date of the notice of the coverage decision. You may file an appeal for any of the following reasons:
- Fallon Health refuses to cover or pay for services you think we should cover.
- Fallon Health or one of your plan's contracted medical providers refuses to give you a service you think should be covered.
- Fallon Health or one of your plan's contracted medical providers reduces or cuts back on services you have been receiving.
- You think that Fallon Health is stopping your coverage too soon.
Note: The 60-day limit may be extended if you have a good reason (“good cause”). Include in your written request the reason why you could not file within the 60-day time frame.
When will a decision be made?
Standard appeals:
- If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal request if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
- If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within seven calendar days after we receive your appeal.
- However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to 14 more calendar days for Medicare Part C services.
- If you believe that we should not take extra days, you can file a fast grievance about our decision to take extra days. When you file a fast grievance, we will give you an answer to your complaint within 24 hours.
- If we do not give you an answer by the deadline above (or by the end of the extended time period if we took extra days), we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
- If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.
- If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 Appeal.
Fast appeals:
- For a request for a medical item, service or Medicare Part B drug, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
- However, if you ask for more time, or if we need to gather more information that may benefit you, we can take up to an additional 14 calendar days for Medicare Part C services. If we decide to take extra days to make the decision, we will tell you in writing.
- If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
- If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
- If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for a Level 2 appeal.
HOW TO FILE AN APPEAL ABOUT YOUR MEDICARE PART D PRESCRIPTION DRUG COVERAGE
You, your representative or your doctor or other prescriber can call, write, or fax Fallon Health to start your appeal.
Fallon Health
Member Appeals and Grievances
1 Mercantile St., Ste 400
Worcester, MA 01608
Toll-free: 1-800-333-2535, ext. 69950 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. Fast appeals can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.
Fax: 1-508-755-7393
Email: grievance@fallonhealth.org
You can also initiate a Medicare Part D appeal using our online form.
When can an appeal be filed?
- The request must be made within 60 days of receiving the coverage decision.
When will a decision be made?
Standard appeals:
- If we are using the standard deadlines, we must give you our answer within seven calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for a fast appeal.
Fast appeals:
- If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
Member grievances
What is a grievance?
A grievance is a type of complaint you make about a problem that does not involve payment or services by Fallon Health or a contracting medical provider. For example, you would file a grievance:
- If you have a problem with things such as the quality of your care during a hospital stay
- If you feel you are being encouraged to leave your plan
- When you feel waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room are too long
- When you feel you are waiting too long for prescriptions to be filled
- If you are dissatisfied with the way your doctors, network pharmacists, or others behave
- When you are unable to reach someone by phone or obtain the information you need.
Who can file a grievance?
You may file a grievance or someone else may file one on your behalf. You may appoint an individual to act as your representative to file a grievance for you by filling out an Appointment of Representative form (pdf).
How to file a grievance
Contact us promptly—either by phone or in writing.
- Usually, calling us is the first step. If there is anything else you need to do, we will let you know. Our phone number is 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week). 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 Fallon Health, Member Appeals and Grievances, 1 Mercantile St., Ste 400, Worcester, MA 01608, or send it by faxing to 1-508-755-7393.
When can a grievance be filed?
A grievance must be submitted within 60 days of the event or incident.
Expedited grievance
You have the right to request a fast review or expedited grievance if you disagree with our decision to take an extension on your request for an organization determination or reconsideration, or our decision to process your expedited request as a standard request. In such cases, we will acknowledge your grievance within 24 hours of receipt and notify you in writing of our conclusion within 24 hours.
Where can a grievance be filed?
A grievance may be filed in writing directly to Member Appeals and Grievances at the address below. Or, you can call Member Appeals and Grievances at the telephone number listed below:
Fallon Health
Member Appeals and Grievances
1 Mercantile St., Ste 400
Worcester, MA 01608
1-800-333-2535, ext. 69950 (TRS 711)
8 a.m.–8 p.m., Monday through Friday
Fax: 1-508-755-7393
When will I receive a response?
- If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
- Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.
Complaints about quality of care
When your complaint is about the quality of care you received, you have another option:
- You can make your complaint to the Quality Improvement Organization (KEPRO). If you prefer, you can make your complaint about the quality of care you receive directly to this organization (without making a complaint to Fallon Health).
KEPRO
5201 West Kennedy Blvd., Suite 900
Tampa, FL 33609
Phone: 1-888-319-8452
TTY:711
You can also complete a Medicare Complaint Form. (This link takes you away from the Fallon Medicare Plus website.)
KEPRO has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. KEPRO is an independent organization. It is not connected with Fallon Health.
- If you wish, you can make your complaint about quality of care to Fallon Health and to the Quality Improvement Organization (KEPRO) at the same time.
Learn more about appeals and grievances
For more information about appeals and grievances, see your Evidence of Coverage, or call us at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week).
You have the right to get a summary of information about the exception requests and the appeals and grievances that members have filed against our plan in the past. To get this information, ask questions about our process or check the status of an issue, call us at 1-800-325-5669 (TRS 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–March 31, seven days a week).
Contact information
If you need information or help, call us at:
1-800-325-5669 (TRS 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–March 31, seven days a week).
Other resources to help you:
Medicare Rights Center: 1-888-HMO-9050
Medicare: 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048 or visit the Medicare Beneficiary Ombudsman website. (This link will take you away from the Fallon Medicare Plus website.)