Members

Grievance and Appeals

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Are you having problems with your medical care or our services? If so, you have a right to file a grievance or appeal.

A grievance can be filed when you are unhappy with your care. Some examples are:

  • The care you get from your provider;
  • The time it takes to get an appointment or be seen by a provider or;
  • The providers you can choose for care.
     

An appeal can be filed when you do not agree with Senior Whole Health’s decision to:

  • Stop, suspend, reduce or deny a service or;
  • Deny payment for services provided.

 

Filing a Grievance with Senior Whole Health

If you have a complaint, we encourage you to first call Member Services. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this our Member Grievance Process.

You must file your grievance within 60 days of the event that gives rise to the grievance. You may file a grievance either orally or in writing, by one of the methods below.

  • Fax your complaint to (617) 494-5554
  • Write to:
    Senior Whole Health
    Attn: Quality Manager
    1075 Main Street, Suite 400
    Waltham, Massachusetts 02451
 

We will respond to all quality of care grievances in writing, regardless of how the grievance was filed.

Expedited Grievance Procedure:

You (or your representative, with appropriate authorization) are entitled to an expedited grievance whenever Senior Whole Health takes an extension relating to an organization determination reconsideration, or when we refuse to expedite a request for an organization determination or reconsideration. Senior Whole Health will respond to these grievances with 24 hours after receipt. Our expedited grievance determination will address only your dissatisfaction with our decision to take an extension or deny your request to expedite a determination or appeal. The grievance determination will not address the underlying issue (request for services or payment, etc.) that is the subject of the organization determination or reconsideration. For after hours, weekend, or holiday delivery please contact our Nurse Advice Line which is available 24 hours a day 7 days a week.

Standard Grievance Procedure:

For all other grievances, we will make a decision and notify you of our decision as your case requires based on your health status, but not later than 30 calendar days after receiving your complaint. We may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

Medicare Complaint Form

You may access additional information on Medicare.gov.

How to Appeal a Denial

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. Please call Member Services.

For more information, visit our How to Appeal a Denial page.

Massachusetts Ombudsman Programs

The Community Care Ombudsman Program (My Ombudsman) helps people enrolled in MassHealth (Medicaid) with service or billing problems. They can help you file a grievance or appeal with our plan.

  • Call (855) 781-9898 Monday-Friday, 9 a.m. to 4 p.m.
    • For TTY, dial 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
    • Videophone: (339) 224-6831
  • Write to:
    Community Care Ombudsman Program
    11 Dartmouth Street
    Suite 301
    Malden, MA 02148

 

The Massachusetts State Long-Term Care Ombudsman Program helps people get information about nursing homes and resolve problems between nursing homes and residents or their families.

  • Call (855) 781-9898 Monday-Friday, 9 a.m. to 4 p.m.
    • For TTY, dial 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
  • Write to:
    Massachusetts State Long-Term Care Ombudsman Program
    1 Ashburton
    Room 517
    Boston, MA 02108

 

Senior Whole Health wants you to have access to the grievance process. We will provide you with help through each step. For any other questions, Please call Member Services. *Printed copies of information posted on our website are available upon request.