Medical Prior Authorizations, Appeals, and Grievances
Some medical procedures require prior authorization. If you need help understanding your options, we can help!
At Mass Advantage, part of loving your plan is having the freedom to speak up and be heard when you disagree with a decision we've made - or if you have a complaint you'd like to share with us. That's what we mean by "appeals and grievances."
If your medical procedure requires a prior authorization, you or your doctor can use the Outpatient Form or Inpatient Form to complete the request.
Under medical plans, some treatments and medications may need approval from your health insurance carrier before you receive care. Prior authorization is usually required if you need a complex treatment. Prior authorization may be needed before getting outpatient services in a hospital or hospital-affiliated facility. Review your plan documents or call the number on your health plan ID card for more information about the treatments, services, and supplies that require prior authorization under your specific plan.
If you are unhappy with the coverage determination (the decision made on your request), you may file an appeal. An appeal simply questions a decision we’ve made and asks that it be reviewed and changed. We at Mass Advantage will review the decision as you requested and respond to you in a reasonable amount of time.
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.
Who Can File an Appeal?
An appeal may be filed by any of the following:
- You.
- Your doctor.
- Another health care provider or prescriber.
- You can appoint a representative to act on your behalf for filing a coverage determination by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website.
When Can an Appeal be Filed?
You must make your appeal request within 65 calendar days from the date of the denial letter informing you of a denial or other adverse benefit determination. If you miss this deadline and have good cause, we may give you more time to appeal. You will need to provide a written explanation why your appeal is late so we can determine if there is good cause to process the untimely appeal. Examples of good cause for missing the deadline may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal.
It’s important for us to know if you’re ever unhappy with how we serve you. If you have a complaint about any aspect of your Mass Advantage plan – from the quality of care to waiting too long for a prescription – you can file 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."
Who Can File a Grievance?
A grievance may be filed by any of the following:
- You.
- You can appoint a representative to act on your behalf for filing a coverage determination by providing us with a completed Appointment of Representative Form or visit the CMS Medicare website.
Why File a Grievance?
We provide meaningful procedures for timely hearing and resolution of grievances or complaints. We also have a protocol for escalation of grievances when warranted or requested. A grievance is different from an appeal because usually it will not involve medical coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Examples of a grievance include dissatisfaction with your medical care, poor customer service, lack of respect for your privacy, poor or hard-to-understand written communications and a lack of timeliness in our handling of coverage decisions and appeals.
When Can a Grievance be Filed?
You may file the grievance within 65 calendar days after you had the problem you want to complain about.
Where Can an Appeal or Grievance be Filed?
To start your appeal or grievance, you (or your representative or your doctor or other provider/prescriber) must contact us.
- Send us an expedited or standard appeal or grievance in writing:
Mass Advantage
P.O. Box 64806
ATTN: MPD-1100UR
St. Paul, MN 55164-0811 - Send appeals for Part D Prescription Drugs via email: MedDResponseTeam@primethereapeutics.com
- Send us a Fax:
For Medical Care: (888) 656-7783
Appeals for Part D Prescription Drugs: (888) 904-1139
From October 1 to March 31, we're available 7 days a week from 8 am to 8 pm EST. From April 1 to September 30, we're available Monday through Friday from 8 am to 8 pm EST.
You may call us for standard and expedited appeals:
- For HMO Members: (844) 918-0114
- For PPO Members: (844) 915-0234
From October 1 to March 31, we're available 7 days a week from 8am to 8pm EST. From April 1 to September 30, we're available Monday through Friday from 8am to 8pm EST.
You can also file a grievance directly with Medicare by filing out the Medicare Complaint Form.
How Can I Request Information Related to Grievances, Appeals and Exceptions?
You may request aggregate numbers of grievances, appeals, and exceptions filed with the plan, or specific information regarding the status of grievances or appeals you have filed, by calling Member Services.
You can give permission to allow an authorized representative — like a trusted friend or family member — to help you with forms or make requests for you.
Questions?
We’re here to help.
HMO: (844) 918-0114
PPO: (844) 915-0234
TTY: 711
From October 1 to March 31, we’re available 7 days a week from 8am to 8pm EST. From April 1 to September 30, we’re available Monday through Friday from 8am to 8pm EST.