Initial Decisions, Appeals, and Grievances
Important Information
For important information about initial decisions, appeals, and grievances, select one of the links below:
- Medicare Advantage Part C-Requests for Medical Care or Services (H8578_2009_009R1 Approved 10/02/2008)
- Medicare Advantage Part D-Requests for Prescription Drugs (H8578_2012_032 Approved 08/23/2011)
These documents explain the processes for requesting initial decisions (another term for Coverage Determinations, which includes requests for Prior Authorization and Exceptions), appeals, and grievances. 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 the Evidence of Coverage.
For more information about Prescription Drug (Medicare Part D) Limitations/Exceptions, select the link below:
How to request an Initial Decision or Appeal or Submit a Grievance
You, your prescriber, treating provider, or authorized representative may request an initial decision or appeal using the contact information in the table below. You or your authorized representative may also submit a grievance using the contact information below.
For more information on how to authorize someone to represent you during an appeal, select the link: Privacy Notice and Appointing a Representative.
Check on the status of a request or grievance
You may also check on the status of a request or grievance by calling one of the numbers below.
How to request a report
Request a report on the total number of grievances, appeals, and exceptions filed with the HNE Medicare Advantage Plan by calling Member Services or sending a written request to our Complaints and Appeals Department at the address listed below.
Contact Us
Medicare Part C Medical Care Initial Decisions (Organization Determination) |
Medicare Part C Medical Care Appeals (Reconsideration) and Grievances |
Contact us by telephone: Local: 1-413-787-0010 Or, send written requests to: HNE Medicare Advantage Plan Fax: 1-413-233-2700 |
Contact us by telephone: Local: 1-413-787-0010 Or, send written requests to: Fax: 1-413-233-2685 |
Medicare Part D Prescription Drug Initial Decisions (Coverage Determination/Exception) |
Medicare Part D Prescription Drug Appeals (Redetermination) and Grievances* |
Contact our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), by telephone: Toll-Free: 1-800-546-5677 Or, send written requests to: Medicare Part D Coverage Determinations Fax: 1-866-632-7946 Forms:
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Contact our Pharmacy Benefit Manager, National Pharmaceutical Services (NPS), by telephone: Toll-Free: 1-800-546-5677 Or, send written requests to: Medicare Part D Appeals Fax: 1-866-632-7946 * 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. |
Contact Medicare
You can also contact the Centers for Medicare & Medicaid (CMS) directly:
- Direct access to the CMS Complaint Form (use this form to provide feedback directly to Medicare about a Medicare health plan or prescription drug plan, including HNE Medicare Advantage; if you would like to request an initial decision, appeal an HNE Medicare Advantage initial decision, or submit a grievance, we encourage you first to contact HNE Medicare Advantage Member Services at one of the number listed above.
- Direct access to the CMS Ombudsman (the Office of the Medicare Ombudsman helps you with complaints, grievances, and information requests).
