Grievances

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

  • You.
  • Someone else may file a grievance for you.If you would like, you can name another person to act for you as your “representative” to file a grievance on your behalf.
    • There may be someone who is already legally authorized to act as your representative under State law.
    • If you want a friend, relative, your doctor or other provider, or other person to be your representative, click here to obtain the “Appointment of Representative” form.The form gives that person permission to act on your behalf. It must be filled out and signed by you and by the person who you would like to act on your behalf.You must give us a copy of the signed form.
    • 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.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with Mass Advantage or a contracting medical provider or pharmacy.

When can a Grievance be filed?

You may file the grievance within 60 calendar days after you had the problem you want to complain about.

Where can a Grievance be filed?

A grievance may be filed orally or in writing directly to us.

Filing a grievance with our plan

The process for filing a grievance is different from the process for coverage decisions and appeals. Contact us promptly either by phone or in writing if you you would like to file a grievance.

Call us:

H7670 Plan 001 and 002 (HMO):1-844-918-0114, TTY: 711
H9904 Plan 001 (PPO):1-844-915-0234, TTY: 711

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.

If you call us with a complaint, we may be able to give you an immediate answer by phone.

Calls to this number are free. From October 1st to March 31st, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1st to September 30th, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays.

Member Services also has free language interpreter services available for non-English speakers.

If you do not wish to call (or you called and were not satisfied with the outcome), you can send us your complaint in writing.

Mass Advantage
P.O. Box 1285
Maryland Heights, MO 63043

OR

Email your grievance about Part D Prescription Drugs to: MedDResponseTeam@magellanhealth.com.

OR

Send us a fax: 1-888-904-1139

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.

If you have questions or have an inquiry regarding the status of your grievance please contact Member Services at:

H7670 Plan 001 and 002 (HMO):1-844-918-0114 TTY 711
H9904 Plan 001 (PPO): 1-844-915-0234, TTY: 711

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.

Review your Evidence of Coverage for additional details.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with Mass Advantage’s decision to take an extension or decision to process your expedited level 1 appeal as a standard level 1 appeal.

Mass Advantage will process your grievance as an expedited grievance and will respond to your grievance within twenty-four (24) hours of receipt.

Standard Grievances

If possible, we will answer you right away on grievances filed verbally. If you call us with a complaint, we may be able to give you an immediate by phone. If your health condition requires us to answer quickly, we will do that.

Most complaints are answered within 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. If we need to take extra days, we will tell you in writing.

If you request a written response, file a written grievance, or your complaint is regarding a quality of care complaint, we will respond in writing.Otherwise we may respond verbally.

Filing a grievance with Medicare

You can submit a complaint about Mass Advantage Basic (HMO) directly to Medicare. To submit an online complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx.

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.

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.

Filing a grievance about quality of care to the Quality Improvement Organization

When your complaint is about the quality of care you have received, you have two extra options:

  1. You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us).
    1. The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients.
    2. Please contact Kepro:
      1. Call: 1-888-319-8452

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.

Monday-Friday: 9 a.m.-5 p.m.

Weekends-Holidays: 11 a.m.-3 p.m.

Please note, representatives are not available on weekends and holidays to assist with quality of care concerns.

      1. TTY: 1-855-843-4776
      2. Send written grievance:

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.

Kepro

5700 Lombardo Center Dr., Suite 100

Seven Hills, OH 44131

If you make a complaint to the Quality Improvement Organization, we will work with them to resolve your grievance.

  1. Or if you wish you can make your complaint to us and also to the Quality Improvement Organization, at the same time.

Request Appeals and Grievance Data

You have a right to request Mass Advantage general data regarding the number and handling of appeals and grievances members have filed with the plan.Please contact Member Services at:

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.