Appeals & Grievances

Appeals & Grievances

What is an Appeal?

An appeal is asking us to review and change a coverage decision (initial determination) we have made regarding adverse benefit determination (a decision unfavorable to you), or the amount of cost share we assigned to you. If you receive a denial letter informing you of a denial or other adverse benefit determination and you are not satisfied with this decision, you may file an appeal.

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What is a Grievance?

A grievance is a type of complaint you make if you have a complaint with any aspect of the operations, activities or behavior of a plan or its delegated entity in the provision of health care items, services, or prescription drugs. For example, you would file a grievance if you have a complaint related to the quality of care you received, waiting too long for prescriptions to be filled, lack of cleanliness of a clinic, hospital, or doctor’s office, poor customer service experience, or other negative behaviors from your doctors, network pharmacists or others providing care. If you experience any of these issues and would like to file a complaint, it is called "filing a grievance."

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Appoint a Representative

In order for Mass Advantage to process a Grievance or/and Appeal request from someone other than you (the member), your physician, your prescribing physician (Part D), or other prescriber (Part D), we must have authorization from you. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and the representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request for you after sending us the legal representative form. You will not need to complete an Appointment of Representative Form if you provide an equivalent written notice or other legal representation document with your request.

For instructions on how to appoint a representative, click here.

To appoint a representative, you or your representative should complete the form entitled:Appointment of Representative CMS - 1696.

If you need a large print version of CMS 1696, click here.

You may submit an equivalent written notice in lieu of the Appointment of Representative form:

  • Be in writing and signed and dated by you and your representative;
  • Provide a statement appointing the representative to act on your behalf;
  • A statement that the enrollee is authorizing the representative to act on his or her behalf for the issue, and a statement authorizing disclosure of individually identifying information to the representative;
  • Include a written explanation of the purpose and scope of the representation;
  • List your name and your representative’s names, phone numbers, and addresses;
  • Include your Medicare Beneficiary Identifier or Mass Advantage ID number from your ID card;
  • Indicate your representative’s professional status, if any, or relationship to you; and
  • Be filed with the entity processing your request.

Unless revoked, an appointment is considered valid for one year from the date the form is signed. Once the form is filed, it is valid for the duration of the appeal. Therefore, a signed form can be used for more than one appeal as long as the appeal is filed within one year of the date on the form.

In addition, there are certain individuals who can bring an appeal on your behalf, pursuant to State or other applicable laws.  Such an individual, known as an "authorized representative," may be a court-appointed guardian, an individual who has durable power of attorney, a health care proxy, or a person designated under a State's health care consent statute.

You also can get the Appointment of Representative form on CMS's website.

Contact numbers for members and physicians who have questions and need to inquire about the status of the Grievance and/or Appeal processes

Members/Providers

Please call the Mass Advantage Member Services Department: 

Call Mass Advantage Member Services

HMO: 844-918-0114
PPO: 844-915-0234 

From October 1 to March 31, we’re available 7 days a week from 8 a.m. to 8 p.m. EST. From April 1 to September 30, we’re available Monday through Friday from 8 a.m. to 8 p.m. EST 

You can also find detailed information regarding grievances and the appeals process in the Mass Advantage Evidence of Coverage (EOC)