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Medical and Pharmacy Appeals

An appeal is a request from you or your doctor when you’d like Commonwealth Care Alliance (CCA) to re-evaluate a decision we made about what medical care, services, supplies, or prescriptions are covered.

Appeals need to be filed within 60 calendar days of the date on the denial notice you receive for a coverage determination or organization determination. CCA can accept an appeal beyond 60 days if good cause for an extension is shown.

Medical Appeals

You, your doctor, or an appointed representative have the right to file an appeal if we denied coverage for medical care, services, or supplies.

A standard appeal is answered within 30 days. An expedited appeal receives a response within three days. An expedited appeal requires a statement from your doctor indicating an urgent need.

There are two ways you, your doctor, or your appointed representative may file a medical appeal:

  1. Call us at: 866-610-2273 (TTY 711)
  1. Mail or fax your written appeal to:
    Commonwealth Care Alliance
    Appeals and Grievances Department
    30 Winter Street
    Boston, MA 02108
    Fax: 857-453-4517

Members will receive an Appeal Acknowledgement Letter once the appeal has been initiated. This letter will document the next steps of the appeal process as well as the timeframe within which CCA must respond to the appeal based on the request type (standard vs. expedited).

If your Level 1 appeal is denied by Commonwealth Care Alliance, you may file a Level 2 appeal with MassHealth. If you wish to appeal with MassHealth, you may do so, no later than 120 calendar days from the date you received your written appeal denial notice from us. You will be sent a form to file a State Fair Hearing Request with your appeal denial.

If you would like to name a representative to appeal on your behalf, the request must be signed and sent by mail or fax to:

Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Fax: 617-847-1204

Please keep one copy of your MassHealth fair hearing request for your records. If you do not agree with the fair hearing decision, you will have more appeal rights under MassHealth and Medicare. You will be notified of those appeal rights.

Pharmacy Appeals

You, your doctor, or an appointed representative have the right to file an appeal if we denied coverage for your prescription drugs.

A standard appeal is answered within seven days. An expedited appeal receives a response within 72 hours. An expedited appeal requires a statement from your doctor indicating an urgent need.

There are two ways you, your doctor, or an appointed representative may file a pharmacy appeal:

  1. Call us at: 866-610-2273 (TTY 711)
  2. Mail or fax a Request for Redetermination Form to:

Commonwealth Care Alliance
Appeals and Grievances Department
30 Winter Street
Boston, MA 02108
Fax: 857-453-4517

Members will receive an Appeal Acknowledgement Letter once the appeal has been initiated. This letter will document the next steps of the appeal process as well as the timeframe within which CCA must respond to the appeal based on the request type (standard vs. expedited).

Grievances

A grievance is a complaint about any aspect of your experience with CCA, its providers, or vendors other than coverage or payment decisions (these issues are usually handled by the appeal process). You might file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You could also file a grievance if you do not think we responded quickly enough to your request for coverage determination or organization determination, or to your appeal of that determination.

There are four ways you or your appointed representative may file a grievance :

  1. Call us at: 866-610-2273 (TTY 711)
  2. Mail or fax your grievance to:

Commonwealth Care Alliance
Appeals and Grievances Department
30 Winter Street
Boston, MA 02108
Fax: 857-453-4517

  1. Submit your grievance to Medicare.

Submit your complaint directly to Medicare by using their online form* or by calling 800-MEDICARE (800-633-4227 or TTY 877-486-2048), 24 hours a day, 7 days a week.

  1. Submit your grievance to MassHealth.

MassHealth Customer Service Center
800-841-2900 (TTY 800-497-4648)
Monday to Friday, 8 am to 5 pm

*When you click this link, you will leave the Commonwealth Care Alliance website.

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866-610-2273 (TTY 711)
8:00 am to 8:00 pm, Monday through Friday, and 8:00 am to 6:00 pm, Saturday and Sunday