Member Grievances

What is a grievance (complaint)?

A grievance is a type of complaint you make about a problem that does not involve payment or services by Senior Whole Health or a contracting medical provider. For example, you would file a complaint:
  • If you have a problem with things such as the quality of your care during a hospital stay
  • If you feel you are being encouraged to leave your plan
  • When you feel waiting times on the phone, at a network pharmacy in the waiting room, or in the exam room are too long
  • When you feel you are waiting too long for prescriptions to be filled
  • If you are dissatisfied with the way your doctors, network pharmacists or others behave
  • When you are unable to reach someone by phone or obtain the information you need

Who can file a complaint?

You may file a complaint or someone else may file the complaint on your behalf. You may appoint an individual to act as your representative to file a complaint for you by filling out a personal representative authorization form.

How to file a complaint

Contact us promptly – either by phone or in writing.
  • CALL:
    • 1-888-794-7268 (TTY/TDD 711)
  • FAX:
    • 1-617-494-5554
  • WRITE:
    • Senior Whole Health
      Attention: Member Services
      58 Charles Street
      Cambridge, MA 02141

When can a complaint be filed?

A complaint must be submitted within 60 days of the event or incident. You have the right to request a fast review or expedited complaint in some cases. A "fast complaint" means that we will notify you in writing of Senior Whole Health's conclusion within 24 hours.

How long will it take to get a decision?

  • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
  • Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

What happens next?

You may also make a complaint to the Quality Improvement Organization (KEPRO).

  • CALL:
    • 1-888-319-8452

      Hours of operation:
      Monday - Friday: 9:00 a.m. to 5:00 p.m.
      Weekends and Holidays: 11:00 a.m. to 3:00 p.m.
      24 hour voicemail service is available
  • TTY:
    • 855-843-4776

      This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

If you prefer, you can make your complaint about the quality of care you receive directly to this organization (without making a complaint to us) or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization.

For more information about the complaints process, see your Evidence of Coverage, or call us at 1-888-794-7268 (TTY/TDD 711), 8 a.m. to 8 p.m., 7 days a week.

Last Updated 10/11/2019