Inquiries Appeals & Grievances

Inquiries, appeals and grievances

 

Whenever you have a question or need help using plan providers and services, FHLAC encourages you to contact Customer Service. If you have a question or concern regarding an adverse determination or if you would like to file an appeal or grievance, contact the Member Appeals and Grievances Department.

An adverse determination means that FHLAC has made a decision, based on the review of information provided to us, that denies, reduces, modifies, or terminates coverage for health care services. This includes, but is not limited to, cases where the treatment does not meet the requirements for coverage based on medical necessity, appropriateness of health care setting and level of care or effectiveness.

Making an inquiry

If you have a question or need help with an issue that is not about an adverse determination, contact Customer Service. You can reach our Customer Service Representatives in the following ways:

Call: 1-800-868-5200
(TTY users, please call TRS relay 711)
Monday, Tuesday, Thursday, and Friday from 8 a.m. to 6 p.m. and Wednesday from 10 a.m. to 6 p.m.

E-mail: customerservice@fchp.org

Write: Fallon Health & Life Assurance Company, Inc.
Customer Service Department
10 Chestnut St.
Worcester, MA 01608

In most cases, our Customer Service Representatives will be able to answer your question or handle your request the first time you call. In some cases, however, FHLAC may need to do more research before FHLAC completes your request. In these cases, FHLAC will make every effort to provide you with a response within three business days.

Filing an appeal: internal appeal review

If you disagree with an adverse determination about coverage related to your care, you may file an appeal. An appeal is a request to change a previous decision made by FHLAC. A rescission of coverage may also be appealed.

You may file the appeal yourself, or with the completion of the appropriate authorization form, you may have someone else (e.g., a family member, friend, physician/practitioner) do this for you. You must file your appeal within 180 calendar days from when you received the written denial.

If you file an appeal, be sure to give us all of the following information:

  • The member’s name
  • The FHLAC identification number
  • The facts of the request
  • The outcome that you are seeking
  • The name of any representative with whom you have spoken

You can file an appeal in any of the following ways:

Write: Fallon Health & Life Assurance Company, Inc.
Member Appeals and Grievances Department
10 Chestnut St.

Worcester, MA 01608

Call: 1-800-333-2535, extension 69950
(TTY users, please call TRS relay 711)
Monday through Friday, 8:00 a.m. to 5:00 p.m.

E-mail: grievance@fchp.org

Fax: 1-508-755-7393

In person: Fallon Health & Life Assurance Company, Inc.
Member Appeals and Grievances Department
10 Chestnut St.
Worcester, MA 01608

If you send us a written or electronic appeal, we will acknowledge your request in writing within 15 business days from the date we receive the request, unless you and the plan both agree in writing to waive or extend this time period. We will put an oral appeal made by you or your authorized representative in writing and send the written statement to you or your authorized representative within 48 hours of the time that we talked to you, unless you and the plan both agree in writing to waive or extend this time period.

We will complete our review and send you a written response within 30 calendar days from the date that we receive your request. These time limits may be waived or extended if you and the plan both agree in writing to the change. This agreement must note the length of the extension, which can be up to 30 days from the date of the agreement.

You have the right to provide any additional information, including evidence and allegations of fact or law, in support of your appeal. This may be done in person or in writing. Any new information received by FCHP during the course of the appeal may be sent to you for review. At any point before or during the appeal process, you may examine your case file, which may include medical records or any other documentation and records considered during the appeals process.

In some cases, FHLAC will need medical records to complete our review of your appeal. If we do, we may ask you to sign a form to authorize your provider to release the records to us. If you do not send this form within 30 calendar days from receipt of your appeal, FHLAC will complete the review based on the information that we do have, without the medical records.

Your appeal will be reviewed by individuals who are knowledgeable about the matters at issue in the appeal. If your appeal is about an adverse determination, the reviewer will be an individual who did not participate in any of the plan’s prior decisions on the issue. The reviewer may consult with a health care professional who is actively practicing in the same or similar specialty that is the subject of your appeal.

Our response will describe the specific information we considered as well as an explanation for the decision. If the appeal is about an adverse determination, the written response will include the clinical justification for the decision, consistent with generally accepted principles of professional medical practice; the information on which the decision was based; pertinent information on your condition; alternative covered treatment options as appropriate; clinical guidelines or criteria used to make the decision.

Opportunity for reconsideration

If relevant information was received too late, or is expected to become available within a reasonable time period, for internal review, you may ask for a reconsideration of a final adverse determination.

In this case, FHLAC would agree in writing to a new time period for review. This would not be longer than 30 days from the date FHLAC agrees to the reconsideration.

Expedited review

FHLAC will conduct an expedited review if your appeal concerns services which:

  1. If delayed, could seriously jeopardize your life or health or your ability to regain maximum function, or;
  2. In the opinion of a physician with knowledge or your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your appeal.

If a physician with knowledge of your medical condition determines an expedited review is necessary, your appeal shall receive an expedited review. Your request for an expedited appeal may be submitted orally or in writing by you or your representative. FCHP will make a decision on your expedited appeal within 72 hours.

Filing an appeal: external appeal review

An external appeal is a request for an independent review of the final decision made by FHLAC through its internal appeal process. If your appeal involved an adverse determination, and you are not satisfied with our final decision, you have the right to file the case with an external review agency. You must request this in writing within four months from receiving the written notice of the final adverse determination.

If the subject matter of the external review involves the termination of ongoing services, you may apply to the external review panel to seek the continuation of coverage or treatment. You must file this request by the end of the second business day after receiving the final adverse determination. If the external review agency finds that termination of the services would cause you substantial harm, they may order continuation of coverage at our expense, regardless of the final external review determination.

In any case where we fail to meet our internal timelines, you have the right to file an external review, even if you have not yet exhausted our internal appeals process.

Expedited external review

You may request an expedited (fast) external review. You may request an expedited external review under the following circumstances:

  • Your appeal involves a medical condition for which the timeframes for completion of a standard appeal would seriously jeopardize your life, health, or ability to regain maximum function
  • Your appeal involves an admission, availability of care, continued stay, or health care item or service for which you have received emergency services, but have not been discharged from the hospital

You may file an expedited external review even if you have not yet received a decision through our internal appeals process.

Filing a grievance

A grievance is the type of complaint you make if you have any other type of problem with FHLAC or one of our plan providers. You would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office.

If you have a grievance, our Member Appeals and Grievances coordinators are available to assist you in accordance with your rights and in confidence.

You can file a grievance in any of the following ways:

Write: Fallon Health & Life Assurance Company, Inc.
Member Appeals and Grievances Department
10 Chestnut St.
Worcester, MA 01608

Call: 1-800-333-2535, extension 69950
(TTY users, please call TRS relay 711)
Monday through Friday, 8:00 a.m. to 5:00 p.m.

E-mail: grievance@fchp.org

Fax: 1-508-755-7393

Walk-in: Fallon Health & Life Assurance Company, Inc.

Member Appeals and Grievances Department
10 Chestnut St.
Worcester, MA 01608

You may file the grievance yourself, or with the completion of the appropriate authorization form, you may have someone else (e.g., a family member, friend, physician/practitioner) do this for you. You must file your grievance within 180 calendar days from the time the issue arose.

ERISA

As a participant or a beneficiary of an employee welfare benefit plan under ERISA (Employee Retirement Income Security Act of 1974), you may have a right to bring a civil action under ERISA section 502(a) following an adverse benefit determination. Please see your Summary Plan Description provided by Teamsters Local 170 Health and Welfare Fund for a complete statement of your rights.