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:

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:

Division Acknowledged within: Addressed in writing within:
Commercial and Tufts Health Direct Five business days 30 calendar days
Senior Products 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 Public Plans One business day (MA), five business days (RI) 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 9193
Watertown, MA 02471-9194
Commercial – RI 800.682.8059 617.972.9509 Tufts Health Plan
Attn: Appeals and Grievances Department
P.O. Box 9193
Watertown, MA 02471-9194
Senior Products 800.701.9000 617.972.9516 Tufts Health Plan
Attn: Appeals and Grievances
P.O. Box 9193
Watertown, MA 02471-9194
Tufts Health Public Plans - MA 888.257.1985 617.972.9509 Tufts Health Plan
Attn: Appeals and Grievances Department
P.O. Box 9193
Watertown, MA 02471-9194
Tufts Health Public Plans – RI 866.738.4116 857.304.6406 Tufts Health Plan
Attn: Grievance Coordinator
P.O. Box 9193
Watertown, MA 02471-9194
Tufts Health Unify 855.393.3154 857.304.6342 Tufts Health Plan
Attn: Appeals and Grievances Department
P.O. Box 9193
Watertown, MA 02471-9194
 

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
 

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