Appeals and grievances

Fallon Health Weinberg-HMO SNP offers comprehensive care coordination and supportive services to promote continued independence. If you have a problem or concern, you may file a complaint. Fallon Health Weinberg must handle all complaints fairly. You will not be penalized for raising your concerns. You also have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, or to ask questions about our process or to check the status of an issue, call us at 1-800-333-2535 ext. 69950 (TTY 711), 8 a.m.-6 p.m.

For more information, see your 2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf), (you can find the information in Chapter 9), or call us at 1-800-333-2535 ext. 69950 (TTY 711), 8 a.m.-6 p.m.

Coverage decisions about your medical care

A coverage decision is a decision we make about what services we will cover for you. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist.

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

CALL

1-855-561-7247
8 a.m.-5 p.m.
Calls to this number are free.

TTY

(TTY 711)

FAX

1-508-368-9700 for a standard coverage decision
1-508-368-9133 for a fast coverage decision

WRITE

Fallon Health
Attn: Fallon Health Weinberg
Prior Authorization Department
10 Chestnut Street
Worcester, MA 01608

For more information about coverage decisions, see your 2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf). (You can find the information in Chapter 9.)

Coverage decisions about your Part D prescription drugs

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs.

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

CALL

1-866-412-5379 (TTY 711)
Calls to this number are free.

FAX

1-855-633-7673

WRITE

CVS Caremark
MC 109
P.O. Box 52000
Phoenix, AZ 85072-2000

WEBSITE

You can request a Part D coverage decision (also called a coverage determination) using our online form. You can also get this form on the CMS website. (This link takes you away from the Fallon Health Weinberg website.)

For more information about Part D coverage decisions, see your 2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf). (You can find the information in Chapter 9.)

Appeals

An appeal is a formal way of asking us to review our coverage decision. For example, we might decide that a service or drug that you want is not covered or is not medically necessary for you. If you disagree with our decision, you can ask Fallon Health Weinberg to review our decision by asking us for a Level 1 Appeal (sometimes called an “internal appeal” or “plan appeal”). You can ask to see the medical records and other documents we used to make our decision any time before or during the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.

You must ask for a Level 1 Appeal within 60 days after you get an unfavorable notice. We may give you more time if you have a good reason for missing the deadline.

If you are appealing because Fallon Health Weinberg plans to reduce or stop a service you were already getting, you have a right to keep getting that service from Fallon Health Weinberg during your appeal. If you want the service to continue, you must ask for an appeal.

For more information about appeals, see your 2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf). (You can find the information in Chapter 9.)

If you want someone else to request an appeal for you

Your provider can request the appeal on your behalf. If you want a relative, friend, attorney, or someone besides your provider to make the appeal for you, you must first complete a Personal Representative Authorization Form - Filing an Appeal (pdf). This form, which is sometimes called a PRA form, gives the other person permission to act for you.

To get a PRA form:

  • call Fallon Health Weinberg-HMO SNP Customer Service at 1-855-561-7247 (TTY 711), 8 a.m.–8 p.m., Monday–Friday (Oct. 1–Feb. 14, seven days a week), or
  • download the form from the Medicare website. (This link takes you away from the Fallon Health Weinberg website).

We must receive the completed PRA form before we can review your request, if the appeal comes from someone besides you or your provider.

There are two kinds of Level 1 Appeals

  • Standard Appeal – must give you a written decision on a non-drug standard appeal within 30 days after we get your appeal. Our decision might take longer if you ask for an extension, or if we need more information about your case. We’ll tell you if we’re taking extra time and will explain why more time is needed.
  • Fast (Expedited) Appeal – Fallon Health Weinberg must give you a decision on a fast (expedited) appeal within 72 hours after we get your appeal request. You can ask for a fast appeal if you or your health care provider believe your health, life or ability to regain maximum function may be put at risk by waiting up to 30 days for a decision.

We’ll automatically give you a fast appeal if your health care provider asks for one for you or supports your request. If you ask for a fast appeal without support from your health care provider, we’ll decide if your health requires a fast appeal. If we don’t give you a fast appeal, we’ll give you a decision within 30 days.

How to make a Level 1 Appeal

You or your authorized representative must ask for a Level 1 Appeal within 60 calendar days of getting an unfavorable written notice.

When you make your standard or fast appeal, you should give us the following information:

  • Your name
  • Address
  • Member number
  • Primary language (need for interpreter)
  • Reason for appealing
  • Any evidence you want us to review, such as medical records, health care providers’ letters, or other information that explains why you need the item or service. Call your health care provider if you need this information.

To ask for an appeal, call, write, or fax us, or ask your representative or doctor to ask us for an appeal.


CALL

1-800-333-2535, ext. 69950
Monday–Friday, 8 a.m.–6 p.m.
Calls to this number are free.
“Fast” appeals can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

TTY

TRS 711

“Fast” appeals can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

FAX

1-508-755-7393 or 1-716-810-1911

WRITE

Fallon Health
Attn: Fallon Health Weinberg
Member Appeals and Grievances
10 Chestnut Street
Worcester, MA 01608

What happens next?

If you asked for a Level 1 Appeal, you will get a written notice from Fallon Health Weinberg that tells you our decision about your appeal.

If we continue to deny your request for a service, you have other options.

In some cases, we’ll also automatically send your case to an independent Medicare reviewer. If the independent Medicare reviewer denies your request, the written decision will explain your additional appeal rights.

Contact information

To get more information, or to ask questions about our process or to check the status of an issue, call us at:
1-800-333-2535, ext. 69950 (TRS 711)
Monday–Friday, 8 a.m.–6 p.m.

Other resources to help you:

  • Medicare: 1-800-MEDICARE (1-800-633-4227 or TTY: 1-877-486-2048)
  • Medicare Rights Center: 1-888-HMO-9050

How to file a grievance or make a complaint

A grievance is a type of complaint. You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal.)

To make a complaint, call, write, or fax us, or ask your representative to make a complaint.

CALL

1-800-333-2535, ext. 69950
Monday–Friday, 8 a.m.–6 p.m.
Calls to this number are free.

“Fast” complaints can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

TTY

TRS 711
“Fast” complaints can be made and are processed 24 hours a day, seven days a week by leaving a voice message at this number.

FAX

1-508-755-7393

WRITE

Fallon Health
Attn: Fallon Health Weinberg
Member Appeals and Grievances
10 Chestnut Street
Worcester, MA 01608

MEDICARE

You can submit a complaint directly to Medicare online. (This link takes you away from the Fallon Health Weinberg website.) You can also call
1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

For more information about complaints, see your 2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf). (You can find the information in Chapter 9.)

 

 

Fallon Health Weinberg is an HMO plan with a Medicare contract and a coordination of benefits agreement with the New York State Department of Health. Enrollment in Fallon Health Weinberg depends on contract renewal.

To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Fallon Health Weinberg website.)

H2470_W_2017_7 Approved 10182016
The information on this page was last updated on 10/1/2017.

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Information before enrolling:
1-855-561-7248 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

Customer Service:
1-855-561-7247 (TTY 711)
8 a.m.–8 p.m., Monday–Friday
(Oct. 1–Feb. 14, seven days a week)

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Member information

2017 Summary of Benefits (H2470_W_2017_6_r1 Accepted 10152016) ►

2017 Evidence of Coverage (H2470_W_2017_1 Accepted 09122016, pdf) ►

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