Coverage decisions, appeals, and grievances

What to do if you have problems or concerns

NaviCare 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 NaviCare. 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 are making coverage decisions whenever we decide what is covered for you and how much Fallon Health will pay. An exception is a special request for the plan to cover a drug or remove restrictions from a drug. A coverage decision for Part C services is called an organization determination.

You can request a Part D coverage decision (also called a coverage determination) using our online form.

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 plan network 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, or if we refused to cover a service or drug you think that you need.

In other words, to find out 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. 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 us to make your request for Fallon Health to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. 

NaviCare Enrollee Services
Fallon Health 
10 Chestnut St. 
Worcester, MA 01608 
Toll-free: 1-877-700-6996 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. (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 your 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 
PO 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 (the member)
  • Someone else on your behalf (authorized representative)
  • Your doctor (or other prescriber)

You may appoint an individual to act as your representative to file an appeal for you by filling out a Personal Representative Authorization form - SCO only or an Appointment of Representative form. 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

  • To start an appeal you, your doctor (or other prescriber), or your representative may 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, 10 Chestnut St., Worcester, MA 01608. You may also ask for an appeal by calling us at 1-877-700-6996 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. or by emailing us at grievance@fallonhealth.org.
  • 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 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 timeframe, your appeal request will be dismissed.
  • 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.
  • You may also use Medicare's complaint form that is available online at Medicare.gov. (This link will take you away from the NaviCare 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:

  • NaviCare refuses to cover or pay for services you think should be covered.
  • NaviCare or one of the contracted medical providers refuses to give you a service you think should be covered.
  • NaviCare or one of the contracted medical providers reduces or cuts back on services you have been receiving, and you disagree with the change(s).
  • You think that NaviCare 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:

  • For a request for a medical item service or Medicare Part B drug, 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.
  • 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 your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

Fast appeals:

  • For a request for a medical item or service, 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. 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 our plan to start your appeal.

Fallon Health
Member Appeals and Grievances
10 Chestnut St.
Worcester, MA 01608
Toll-free: 1-877-700-6996 (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. 

HOW TO MAKE AN APPEAL FOR MASSHEALTH-COVERED BENEFITS, ITEMS AND SERVICES

You can submit your appeal in writing or by calling us

Fallon Health Member Appeals and Grievances
10 Chestnut St.
Worcester, MA 01608
1-800-333-2535, ext. 69950 (TRS 711), Monday–Friday, 8 a.m.–8 p.m.

When can an appeal be filed?

You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented

When will a decision be made?

Standard appeals:

  • For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to.

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 about quality of care, waiting times, customer service, or other concerns. 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

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.

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 a Personal Representative Authorization form - SCO only or an Appointment of Representative form.

How to file a grievance

Contact us promptly—either by phone or in writing.

  • Usually, calling Enrollee Services is the first step. If there is anything else you need to do, we will let you know. Our phone number is 1-877-700-6996 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. (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, 10 Chestnut St., Worcester, MA 01608, or send it by faxing 1-508-755-7393.

When can a grievance be filed?

A grievance must be submitted within 60 days of the event or incident.

When willI 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 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 us).

    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.

    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 our plan.

  • If you wish, you can make your complaint about quality of care to Fallon and to the Quality Improvement Organization (KEPRO) at the same time.

Learn more about appeals and grievances

For more information about your appeals and grievances, see your Evidence of Coverage (you can find the information in Chapter 8), or call us at 1-877-700-6996 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. (Oct. 1–March 31, seven days a week.) You and/or your physician can also call this number to check the status of an appeal or grievance.

You have the right to get a summary of information about exception requests and the appeals and grievances that members have filed against our plan in the past. To get this information or to ask questions about the process or to check the status of an issue, call us at 1-877-700-6996 (TRS 711), Monday–Friday, 8 a.m.–8 p.m. (Oct. 1–March 31, seven days a week.)

Contact information

If you need information or help, call us at:

1-877-700-6996 (TRS 711)
Monday–Friday, 8 a.m.–8 p.m.
(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 takes you away from the NaviCare website.)
  • My Ombudsman: My Ombudsman helps people enrolled in MassHealth (Medicaid). My Ombudsman is an independent organization that helps individuals, including their families and caregivers, address concerns or questions that may impact their experience with a MassHealth health plan or their ability to access their health plan benefits and services. My Ombudsman works with the member, MassHealth, and each MassHealth health plan to help resolve concerns to ensure that members receive their benefits and exercise their rights within their health plan.

    Call: 1-855-781-9898 
    Videophone (for deaf and hard of hearing): 1-339-224-6831 
    Email: info@myombudsman.org
    Website: www.myombudsman.org (This link takes you away from the NaviCare website.)
    Office: 25 Kingston Street, 4th Floor, Boston, MA 02111

 

NaviCare is a voluntary program in association with MassHealth/EOHHS and CMS.

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The information on this page was last updated on 10/1/2023.

Medicare Part D online forms