Helpful Information Initial Decisions, Appeals, and Grievances
How to request an Initial Decision or Appeal or Submit a Grievance
You, your prescriber, treating provider, or authorized representative may request an initial decision or appeal using the contact information in the table below. You or your authorized representative may also submit a grievance using the contact information below.
To file an appeal or grievance with Health New England Medicare Advantage, fill out and return our Complaint Form.
For more information on how to authorize someone to represent you during an appeal, select the link: Privacy Notice and Appointing a Representative.
For a complete description of these processes, refer to the section titled, "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)," in the Evidence of Coverage.
For more information about Prescription Drug (Medicare Part D) Prior Authorization, Step Therapy and Quantity Limits, select the link below:
Check on the status of a request or grievance
You may also check on the status of a request or grievance by calling one of the numbers below.
How to request a report
Request a report on the total number of grievances, appeals, and exceptions filed with the HNE Medicare Advantage Plan by calling Member Services or sending a written request to our Complaints and Appeals Department at the address listed below.
Contact Us
Medicare Part C Medical Care Initial Decisions (Organization Determination) |
Medicare Part C Medical Care Appeals (Reconsideration) and Grievances |
Contact us by telephone: Local: 413.787.0010 Or, send written requests to: HNE Medicare Advantage Plan Fax: 413.233.2700 To submit a request or check on the status of a request for an organization determination, contact Member Services. Usually, your plan provider will submit a request on your behalf. Your plan provider may also use the HNE Prior Approval Request Form. |
Contact us by telephone: Local: 413.787.0010 Or, send written requests to: Fax: 413.233.2685 |
Medicare Part D Prescription Drug Initial Decisions (Coverage Determination/Exception) |
Medicare Part D Prescription Drug Appeals (Redetermination) and Grievances* |
Contact our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), by telephone: Toll-Free: 800.546.5677 Or, send written requests to: Medicare Part D Coverage Determinations Fax: 866.632.7946 Forms:
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Contact our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), by telephone: Toll-Free: 800.546.5677 Or, send written requests to: Medicare Part D Appeals Fax: 866.632.7946 * If you have a grievance about your Medicare Part D prescription drug coverage, call or write HNE Medicare Advantage Member Services directly (see the contact information for the HNE Medicare Advantage Plan, Complaints and Appeals Department, above). A grievance is any complaint, other than one that involves a request for an initial determination or an appeal. Grievances do not involve problems related to approving or paying for services or Part D drugs. It is a type of complaint that you make if you have any other type of problem with the HNE Medicare Advantage Plan or one of our plan providers. |
Contact Medicare
You can also contact the Centers for Medicare & Medicaid (CMS) directly:
H8578_2016_049 Approved
The information on this page was last updated on 2/18/2016