Coverage Decisions, Appeals & Grievances

• Requesting a Part D (Pharmacy) Request for Coverage Determination Exception, Appeal, or Grievance
• Requesting a Part C (Medical) Request for Organization Determination, Appeal or Grievance

 

Requesting an Organization Determination (for Medical Services)

• Call: (888) 609-0692 , TTY 711
   
• Fax: (866) 874-0857
   
• Mail:
  Harvard Pilgrim Health Care
  Medicare Advantage Organization Determination
  1600 Crown Colony Drive
  Quincy, MA 02169

 

Requesting a Coverage Determination (for a Part D Drug)

• Call: (888) 609-0692, TTY 711
   
• Fax: (844) 403-1028
   
• Mail:
  OptumRx Prior Authorization Department
  P.O Box 25183
  Santa Ana, CA 92799

 

Filing an Appeal or Complaint

• Call: (888) 609-0692, TTY 711
   
• Fax: (617) 509-4232
   
• Mail
  Harvard Pilgrim Health Care
  Medicare Advantage Stride
  Appeals & Grievances
  P.O. Box 328
  Canton, MA 02021

 

Contacting the Centers for Medicare & Medicaid Services (CMS)

• Call: (800) MEDICARE (800-633-4227), TTY (877) 486-2048
   
• Write:
  Centers for Medicare & Medicaid Services
  7500 Security Boulevard
  Baltimore, MD 21244-1850
   
• Visit:
  www.medicare.gov
  Medicare.gov information on filing a complaint
  Medicare.gov information on filing an appeal

For more information about appeals and grievances, see your Evidence of Coverage.

You have the right to obtain an aggregate number of grievances, appeals and exceptions that members have filed against our plan in the past. To get this information, ask questions about our process or check the status of an issue, call us at (888) 609-0692, TTY users please call 711.

Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Stride^SM (HMO) depends on contract renewal.

 

Links on this page may take you away from the Harvard Pilgrim Health Care website.

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Last updated: 1/3/2020