Appeals and Grievances

You Can Ask Us to Reconsider a Decision We Have Made

Have we told you that we will not cover or pay for a medical or pharmacy service? If we make a decision about your coverage and you are not satisfied with it, you can appeal it. An appeal is a formal way of asking us to review and reconsider our decision.

How to File an Appeal

When you file an appeal, we review our original decision to see if we were following all of the rules properly. Your appeal will be handled by different reviewers than those who made the original decision. When we have completed the review, we give you our decision. You need to file an appeal within 60 calendar days of the date listed on the notice of initial coverage decision.

To appeal a decision about a drug

You or your appointed representative can complete the Request for Redetermination of Medicare Prescription Drug Denial form and submit it to us.

To appeal a decision about a medical service

You or your appointed representative can contact us in one of the following ways to tell us that you would like to file an appeal:

  • Call Member Services at 1-855-833-8125 (TTY: 711)
  • Fax your appeal letter with your reasoning for appealing to 617-897-0805
  • Send your appeal letter to:

    Boston Medical Center HealthNet Plan Senior Care Options
    Attention: Member Appeals
    529 Main Street, Suite 500
    Charlestown, MA 02129

If you disagree with the decision about a medical service, you can make another appeal. To learn more about the appeals process, please see your 2021 Evidence of Coverage, which has detailed instructions on how to file appeals. Learn how to get help filing an appeal.

Wish to file a grievance?

If you are dissatisfied with your experience by a doctor, pharmacy, or a staff member of our plan, or if you disagree with a decision we have made, you can file a grievance. Learn how to file a grievance.

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