Initial decisions, appeals, and grievances

We do our best to ensure that everything goes smoothly for you regarding your Health New England Medicare Advantage plan. However, if you do need to contact us regarding an initial decision, appeal, or grievance, there are several ways to do this.


You, your prescriber, treating provider, or authorized representative may use the contact information below to:

  • Request an initial decision or appeal
  • Check on the status of a request or grievance
  • Request a report on the total number of grievances, appeals, and exceptions filed with the Health New England Medicare Advantage

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 your Evidence of Coverage document. If you would like to authorize someone to represent you during an appeal, view the Privacy Notice and Appointing a Representative page.


Making Your Request

You can get your request started by calling us or filling out our Complaint Form and returning it to us by mail. Phone numbers and mailing addresses are listed below, based on the type of request you are making. Be sure to include your name and let us know if you are looking for an initial decision or appeal, checking the status of a request or grievance, or requesting a full report.


Medicare Part C Medical Care Initial Decisions (Organization Determination)

Contact us by phone:
Local: (413) 787-0010
Toll-Free: (877) 443-3314
TTY/TDD: (800) 439-2370
8 a.m. to 8 p.m., 7 days a week

Or, send written requests to:
Health New England Medicare Advantage Plan Clinical Services Department
One Monarch Place Springfield, MA
01144-1500

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 Prior Approval Request Form.


Medicare Part C Medical Care Appeals (Reconsideration) and Grievances

Contact us by phone:
Local: (413) 787-0010
Toll-Free: (877) 443-3314
TTY/TDD: (800) 439-2370
8 a.m. to 8 p.m., 7 days a week

Or, send written requests to:
Health New England Complaints and Appeals Department
One Monarch Place
Suite 1500
Springfield, MA
01144-1500

Fax: (413) 233-2685


Medicare Part D Prescription Drug Initial Decisions (Coverage Determination/Exception)

Contact our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), by telephone:
Toll-Free: (800) 546-5677
TTY/TTD: (866) 706-4757
Seven days a week, 24 hours a day

Or, send written requests to:
Medicare Part D Coverage Determinations
PO Box 407
Boys Town, NE 68010
Fax: (866) 632-7946

Forms:

To submit a request or check on the status of a request for a coverage determination or redetermination, use the “Online Requests” button. Usually, your prescriber will submit a request on your behalf. You or your prescriber may also use the NPS Coverage Determination Request Form.


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
TTY/TTD: (866) 706-4757
Seven days a week, 24 hours a day

Or, send written requests to:
Medicare Part D Appeals
PO Box 407
Boys Town, NE 68010

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.


Centers for Medicare & Medicaid (CMS)

Use the CMS Complaint Form to provide feedback directly to Medicare about a Medicare health plan or prescription drug plan, including Health New England Medicare Advantage. If you would like to request an initial decision, appeal a Health New England Medicare Advantage initial decision, or submit a grievance, we encourage you first to contact our Member Services team.



H8578_2018_049 approved
last updated on 9/30/17