Complaints, Grievances and Appeals

All Tufts Health Plan providers and members have a right to:

• Voice complaints or grievances about Tufts Health Plan, the care provided and those providing care
• File an appeal regarding any adverse decision made by Tufts Health Plan, including service coverage determination or administrative denials
• File an appeal as a member, or as a provider acting on behalf of a member, with the applicable external review entity, listed below, after an adverse action resulting from a final determination (final level of internal Tufts Health Plan review) related to a medical necessity determination:
  • Commercial Plans MA: Massachusetts Office of Patient Protection (OPP)
  • Self-Insured Commercial Plans: Independent Review Entity assigned by Tufts Health Plan
  • Commercial Plans RI: Office of Health Insurance Commissioner
  • Commercial Plans NH: New Hampshire Insurance Department
  • Senior Products: Independent Review Entity
  • Tufts Health Public Plans MA: Medicaid’s Board of Hearings
  • Tufts Health Public Plans RI: Department of Human Services (DHS)
  • Tufts Health Direct: Massachusetts Office of Patient Protection (OPP)

Providers may submit complaints, appeals or grievances as a member’s authorized representative. See the appropriate authorized representative forms below:

• Appointment of Personal Representative – Commercial
• Authorization to Disclose Protected Health Information Form - Tufts Health Plan Senior Care Options (SCO)
• Appointment of Personal Representative – Tufts Medicare Preferred
• Authorized Representative Form – Tufts Health Direct and Tufts Health Together
• Tufts Health RITogether Authorized Representative Form - Tufts Health RITogether
• Appointment of Representative – Tufts Health One Care

For additional information on appeals, grievances and complaints, refer to the applicable Provider Manual for Commercial, Senior Products and Tufts Health Public Plans.

Complaints

Any member or authorized representative may file a complaint by calling the appropriate Tufts Health Plan Member Services phone number. Tufts Health Plan will address all complaints received.

To contact Tufts Health Plan to file a complaint, find the appropriate phone number and hours on the Member Contact Information page.

Grievances

A member or authorized representative may file a grievance. Tufts Health Plan acknowledges and addresses grievances according to the following timelines:

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Division	Acknowledged within:	Addressed in writing within:
Commercial and Tufts Health Direct	Five business days	30 calendar days
Tufts Medicare Preferred and Tufts Health One Care	7 to 10 calendar days	30 calendar days (in writing or verbally)
Tufts Health Plan Senior Care Options (SCO)	One business day	30 calendar days (in writing or verbally)
Tufts Health Together	One business day	30 calendar days
Tufts Health RITogether	Five business days	30 calendar days

 

You may file a grievance by phone, fax or mail:

Division	Phone	Fax	Mail
Commercial – MA	800.462.0224	617.972.9509	Tufts Health Plan Attn: Appeals and Grievances Department P.O. Box 474 Canton, MA 02021
Commercial – RI	800.682.8059	617.972.9509	Tufts Health Plan Attn: Appeals and Grievances Department P.O. Box 474 Canton, MA 02021
Senior Products	800.701.9000	617.972.9516	Tufts Health Plan Attn: Appeals and Grievances P.O. Box 474 Canton, MA 02021
Tufts Health Public Plans - MA	888.257.1985	617.972.9509	Tufts Health Plan Attn: Appeals and Grievances Department P.O. Box 474 Canton, MA 02021
Tufts Health Public Plans – RI	866.738.4116	857.304.6406	Tufts Health Plan Attn: Grievance Coordinator P.O. Box 474 Canton, MA 02021
Tufts Health One Care	855.393.3154	857.304.6342	Tufts Health Plan Attn: Appeals and Grievances Department P.O. Box 474 Canton, MA 02021

 

Appeals

A member, or provider acting on the member’s behalf, may appeal any adverse organization determinations or coverage determinations they believe they are entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the member), or any for which amounts the member must pay.

For detailed information on the Appeals process, see the appropriate Provider Manual and section listed below:

Division	Provider Manual	Chapter
Commercial	Commercial Provider Manual	Member’s Rights and Responsibilities
Senior Products	Senior Products Provider Manual	Member Appeals and Grievances
Tufts Health Public Plans	THPP Provider Manual	Member grievances, appeals, rights and responsibilities