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Organizational Decisions & Appeals

Organizational Decisions | Appeals | What happens next | Other Options | Additional Resources

Organizational Decisions

What is an organizational decision?

An organization decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We are making an organizational decision whenever we decide what is covered for you and how much we pay.

Who can request an organization determination?

You, your doctor, or someone else you appoint may request it on your behalf. You may appoint an individual to act as your representative by filling out a personal representative authorization form. To get the form, call Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website. Click here to view.*

How to request an organizational decision for the medical care you want.

You may file your request orally or in writing.

  • CALL:
    • 1-888-794-7268 (TTY/TDD 711)
  • FAX:
    • 1-617-494-5554
  • WRITE:
    • Senior Whole Health
      Attention: Quality Manager
      58 Charles Street
      Cambridge, MA 02141

How long will it take to get a decision?

When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard organizational decision means we will give you an answer within 14 days after we receive your request.

A fast organizational decision means we will answer within 72 hours.

  • To get a fast organizational decision, you must meet two requirements:
    • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
    • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast organizational decision.
  • If you ask for a fast decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.
If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care you want.

* Please note: By clicking on this link you will be leaving the Senior Whole Health website.

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Appeals

What is an appeal?

If we make an organizational decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change an organizational decision we have made.

Who can file an appeal?

You may file an appeal, someone else may file the appeal on your behalf, or your doctor may file an appeal. You may appoint an individual to act as your representative to file an appeal for you by filling out a personal representative authorization form. (CMS- 1696)

If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. (To get the form, call Member Services and ask for the "Appointment of Representative" form. It is also available on Medicare's website. Click here to view.*

When can an appeal be filed?

The request must be made within 60 days of receiving the coverage decision.

How to request an appeal for the medical care you want.

You may file your appeal orally or in writing.

  • CALL:
    • 1-888-794-7268 (TTY/TDD 711)
  • FAX:
    • 1-855-838-7998
  • WRITE:
    • Senior Whole Health
      Attention: Quality Manager
      58 Charles Street
      Cambridge, MA 02141

How long will it take to get an appeal decision?

If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal (if your appeal is about coverage for services you have not yet received). We will give you our decision sooner if your health condition requires us to.

When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so. The requirements and procedures for getting a "fast appeal" are the same as those for getting a fast organizational decision (see above). If your doctor tells us that your health requires a "fast appeal," we will give you a fast appeal.

* Please note: By clicking on this link you will be leaving the Senior Whole Health website.

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What happens next?

If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 days after we receive your appeal.

If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have automatically sent your appeal to the Independent Review Organization for another review.

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Do I have any other options?

Fair Hearings
You or your authorized representative may ask for a MassHealth Board of Hearings (BOH) review, in addition to, or instead of, filing a standard or expedited appeal with Senior Whole Health. You may download the Fair Hearing Request Form here.

When can a Fair Hearing be filed?
If you choose to ask for a MassHealth BOH appeal, you must submit your written hearing request to BOH within 30 calendar days from the date of mailing of the Senior Whole Health notice to deny coverage for services. If you need help, we can help you with this process.

How do I request a Fair Hearing?
You can use one of the following ways to request a Fair Hearing:
  • CALL:
    • 1-617-847-1200
  • FAX:
    • 1-617-847-1204
  • WRITE:
    • Board of Hearings
      Office of Medicaid
      100 Hancock Street, 6th Floor
      Quincy, MA 02171

You can choose to continue receiving services from Senior Whole Health during the BOH appeal process. If you want to receive such continuing services, you or your authorized appeal representative must submit your BOH appeal request within 10 calendar days from the date of mailing of the Senior Whole Health notice to deny coverage for services and indicate that you want to continue to get these services.

If the BOH decision is not in your favor, you may be financially responsible for the services provided.

If you disagree with the BOH decision, there are further levels of appeals available to you, including judicial review of the decision under Massachusetts General Law.

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If you or your physician have status or process questions please call Member Services at 1-888-794-7268 (TTY/TDD users, please call TRS Relay 711) from 8 a.m. to 8 p.m., seven days a week. You may also request information on the aggregate number of grievances (complaints), appeals, and exceptions filed with the plan.

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You have a right to file a complaint with Medicare at any time.

Medicare
You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form linked to here.

Medicare Complaint Form *

* Please note: By clicking on this link you will be leaving the Senior Whole Health website.

The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program. If you have any other feedback or concerns, or if this is an urgent matter, please call 1-800-MEDICARE (1-800-633-4227). TTY/TTD users can call 1-877-486-2048.

You may contact The Medicare Beneficiary Ombudsman

The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. For more information about The OMO, click here.*

* Please note: By clicking on this link you will be leaving the Senior Whole Health website.

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Last Updated 06/10/2016
H2224_2013_133 Approved 06/21/2013