What is the Tufts Medicare Preferred HMO plan Appeals Policy?

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. Your Evidence of Coverage (EOC) addresses how to file an appeal about your Medicare Advantage Plan which covers Medical and Hospital Services and addresses how to file an appeal about your Medicare Part D Prescription Drug Benefits. These sections give 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.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).