Medicare Advantage Plan 2017

Plan Resources

Member Reimbursement Forms

Evidence of Coverage (EOC)*

Annual Notice of Change (ANOC)*
These documents compare 2016 plans to 2017 plans.

Mail Order Pharmacy Prescription Drug Documents for MedImpact Direct Mail *

Additional Documents


To contact CMS directly you can:

Call: 1-800-MEDICARE (1-800-633-4227) , TTY 1-877-486-2048
Write: Centers For Medicare & Medicaid Services
7500 Security Boulevard
Baltimore. MD 21244-1850

Appeals and Complaints

You can submit your Grievance or Appeal to:

Harvard Pilgrim Health Care
Appeals & Grievances
P.O. Box 690345
Quincy MA 02269

Or, Fax: (617) 509-3085

Appointment of a Representative
You can appoint a representative to help you file an appeal. Your representative can be a family member, friend, advocate, attorney, doctor or someone else who will act on your behalf. There are two ways to appoint a representative:
  1. Fill out an Appointment of Representative form.
  2. Submit a written request with your appeal. Be sure to include:
  • Your name, address, phone number, and Medicare number
  • A statement appointing someone as your representative
  • The name, address, and phone number of your representative
  • The professional status of your representative (like a doctor) or their relationship to you
  • A statement authorizing the release of your personal and identifiable health information to your representative
  • A statement explaining why you’re being represented and to what extent
  • Your signature and the date you signed the request
  • Your representative's signature and the date they signed the request

At some levels in the appeals process, your doctor or prescriber (for prescription drug appeals) can make a request on your behalf without being appointed as your representative.

If you have questions about appointing a representative, call 1-800-MEDICARE.

You can also call Customer Service at (888) 609-0692 to learn more about how to name your appointed representative. TTY users should call 711. We are open from October 1st to February 14th, from 8 8 p.m., 7 days a week and from February 15th to September 30th, from 8 a.m. to 8 p.m., Monday through Friday.

Y0098_17162 Approved Last Update 10/01/2017

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