HMO Appeals & Grievances Processes
What to do if you have complaints
Tufts Medicare Preferred is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to Tufts Medicare Preferred. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.
There are two types of formal complaints you can make. They are appeals and grievances. In this document, we will explain the differences between the two types of complaints and provide a high-level description of the processes for each.
Appeals
We encourage you to let us know right away if you have questions, concerns, or problems related to your Medicare Adavantage Plan which covers Medical and Hospital Services and/or Medicare Part D Prescription Drug Benefits. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way if you make a complaint.
Please note that your Evidence of Coverage (EOC) addresses how to file an appeal about your Part C Medical Services and addresses how to file an appeal about your Part D Prescription Drug Benefits. Your EOC gives the rules for making complaints in different types of situations.
An "appeal" is a complaint you make when you want us to reconsider and change a decision we've made about a request for authorization of services or payment of a denied claim. For example, you can file an appeal if: we refuse to cover or pay for services or Part D drugs you think we should cover; we or one of our plan providers refuses to give you a service you think should be covered; we or one of our plan providers reduces or cuts back on services or benefits you have been receiving, or stops your coverage of a service or benefit too soon.
Grievances
A "grievance" is a complaint you make if you have any other type of problem with Tufts Medicare Preferred or one of our plan providers. For example, you would file a grievance if you have a problem with the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office or pharmacy.
If you have a complaint, we encourage you to call Customer Relations and we will try to resolve the complaint over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a Formal Standard Grievance Process. You must file a grievance either orally or in writing no later than 60 days after the event. We must notify you of our decision no later than 30 calendar days after receiving the complaint. We may extend this timeframe by 14 days at your request, or if we feel it is justified and in your best interest. You can also request an expedited grievance that we must respond to within 24 hours of your complaint.
For more detailed information about appeals and grievances information for both Medicare Advantage and Part D prescription drug benefits, please see your Evidence of Coverage booklet that you receive as a Tufts Medicare Preferred member, or call Customer Relations.
How to file a grievance or appeal:
You, your physician or your appointed representative (authorization of representative form) may file a grievance or appeal by calling Customer Relations or by writing to:
Tufts Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472
Attn: Appeals & Grievance Department
Or by fax to: 1-617-972-9405 or 1-617-972-9487.
How to find additional information about grievances and appeals:
Please see your Evidence of Coverage (EOC) for more information on our grievance and appeals process.
If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact Customer Relations.
PDP Appeals and Grievances
Tufts Medicare Preferred PDP is dedicated to providing its members with prescription drug coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to Tufts Medicare Preferred PDP. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way. There are two types of formal complaints you can make. They are appeals and grievances.
PDP Appeals
An “appeal” is something you do if you disagree with a decision to deny a request for health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our Plan doesn’t pay for a drug, item, or service you think you should be able to receive.
PDP Grievances
A "grievance" is a type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. If you have a complaint, we encourage you to call Customer Relations and we will try to resolve the complaint over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a Formal Standard Grievance Process.
For more detailed information about appeals and grievances information for both Medicare Advantage and Part D prescription drug benefits, please see your Evidence of Coverage booklet or call Customer Relations.
Fraud, Waste, & Abuse
Click here for information about Tufts Health Plan's Fraud, Waste and Abuse Hotline.
