Filing a Grievance

Filing a grievance will not affect your healthcare services. We want to know your concerns so we can improve our services, and address your problems or concerns. We will not hold it against you or treat you differently if you file a Grievance. You can file a Grievance beginning on the date of the situation you are not satisfied with.

You, or your Authorized Appeal Representative, can file CeltiCare Health medical or Behavioral Health Grievances by phone by calling Member Services or you can file a Grievance in writing, by faxing it to 1-866-614-1951, or you can file in person or by mailing it to the address below.

CeltiCare Health
Grievance and Appeal Coordinator - CarePlus
200 West Street, Suite 250
Waltham, MA 02451

In all cases, be sure to include:

  • Your first and last name
  • Your CeltiCare Health or MassHealth CarePlus ID number
  • Your address and telephone number
  • What you are unhappy about
  • What you would like to have happen

After we receive your Grievance, CeltiCare Health will send you a letter within 1 business day of our receipt, letting you know that we have received your Grievance and the expected date of resolution.

If someone else is going to file a Grievance for you, we must have your written permission for that person to file your Grievance. You can call Member Services to receive an Authorized Appeal Representative form, or go to www.CeltiCareHealthPlan.com.

If you have any proof or information that supports and helps explain your Grievance, send it to us and we will add it to your case. You may also request copies of any documentation that CeltiCare Health used to make the decision about your care.

To review your request, we may need additional information. You should include a signed Authorization to Disclose Information form with your Grievance. If you don’t, we will send a form to you for your signature. We need to have a signed authorization from you within 30 calendar days of the request. Without it, CeltiCare Health may issue a decision on the Grievance without being able to review all of your information. You can find the Authorization to Disclose Information form at the back of your Member Handbook and on our website.

Grievance Resolution Time Frame

Once we receive your Grievance, we’ll send you a written letter acknowledging it within 1 business day. We’ll immediately start to work on your Grievance. We’ll send you and your Authorized Representative a written response within 30 calendar days from the date we received your Grievance.

Internal Appeals

There are two types of Internal Appeals; a standard Internal Appeal and an Expedited (fast) Internal Appeal. Either type of Internal Appeal is a request to review an Adverse Action. An Adverse Action is a decision CeltiCare Health made, based on a review of the information provided to deny, reduce, modify, or terminate requested care for you. An Adverse Action can happen when the information provided does not meet the requirements for coverage. The Internal Appeal process gives you an opportunity to ask CeltiCare Health to review this decision.

An Adverse Action or inaction occurs if:

  • We denied or decided to provide limited authorization for a service requested by your healthcare Provider. This can include the decision that the requested service is not a Covered Service.
  • We reduced, suspended or terminated a Covered Service that was previously appealed.
  • We denied, in whole or in part, payment for a Covered Service due to service coverage issues.
  • We did not make a service authorization decision within the allowed timeframes after receiving your request.
  • We did not notify you of a standard Internal Appeal decision within the allowed timeframes after receiving your request.
  • You are not able to obtain healthcare services within the specified timeframes described in your Member Handbook

In most cases, you will receive a notice letting you know that one of the actions listed above has occurred. However, you, or your Authorized Appeal Representative, may file an Internal Appeal whenever one of these actions occurs even if you did not receive a notice from CeltiCare Health.

Who May File an Internal Appeal?

  • You, the Member
  • A person named and authorized in writing by you (Authorized Appeal Representative)
  • Your healthcare Provider

You must give written permission if someone else files an Internal Appeal for you. CeltiCare Health will include an Authorized Appeal Representative form in a letter we send back to you about our Adverse Action decision. Contact Member Services if you need help.

There are two types of Internal Appeals as described below, a standard Internal Appeal and an Expedited (fast) Internal Appeal.

How Do I File a Standard Internal Appeal?

You, or your Authorized Appeal Representative, can file a standard Internal Appeal for all non-Behavioral Health Internal Appeals by phone, by calling Member Services or you can file a standard Internal Appeal in writing, by faxing it to 1-866-614-1951, or you can mail it to the address below. If you or your Authorized Appeal Representative wants to submit a standard Internal Appeal in person please visit us at the address listed below.

CeltiCare Health
Grievance and Appeal Coordinator - CarePlus
200 West Street, Suite 250
Waltham, MA 02451

We handle oral requests for an Appeal as a standard Internal Appeal in order to give you the earliest possible filing date for the standard Internal Appeal. You may be asked to complete a written signed request. If you don’t send us this written documentation, we may dismiss your standard Internal Appeal.

Behavioral Health Standard Internal Appeals

All Behavioral Health related standard Internal Appeals are delegated to CeltiCare Health’s Behavioral Health partner, Cenpatico Behavioral Health (Cenpatico). Cenpatico is obligated to follow the same standard Internal Appeal process as outlined above and in your Member Handbook for CeltiCare Health. For more information please contact Cenpatico directly at 1-866-896-5053.

To file a Behavioral Health standard Internal Appeal in writing please mail or fax the Appeal to the following:

Cenpatico
Attn: Appeals Department
12515-8 Research Blvd, Suite 400
Austin, TX 78759
Fax: 1-866-896-5053
Phone: 1-866-896-5053

When Does a Standard Internal Appeal Have to be Filed?

The Notice of Adverse Action letter CeltiCare Health sends you will tell you that you or your Authorized Appeal Representative have to file a standard Internal Appeal within 30 calendar days from the date of the Notice of Adverse Action, or of learning that an Adverse Action has occurred. There are two levels of standard Internal Appeal – first level and second level.

We provide you with two (2) levels of Internal Appeal review, a first level and a second level (reviewed by a clinician not involved with your first level Internal Appeal). You or your Authorized Appeal Representative must file a first level standard Internal Appeal within 30 calendar days from when we gave you notice that an Adverse Action has been decided. If there is a situation where you do not receive a notice from us, you, or your Authorized Appeal Representative may still appeal within 30 calendar days of learning, on your own, that an Adverse Action or inaction was made on your request. Once your first level standard Internal Appeal request is received, we will send you and your Authorized Appeal Representative a written acknowledgement within 1 business day of receiving it. We will immediately begin to work to resolve your standard Internal Appeal.

Standard Internal Appeal decisions are made by healthcare professionals who have the appropriate clinical background. We use healthcare professionals who were not involved in the original action that you are appealing. Also, if you request a second level review, a different healthcare professional will review the second level standard Internal Appeal.

We will provide you, or your Authorized Appeal Representative, the time to submit comments, documentation, records, present proof and facts, and other information relevant to your standard Internal Appeal. You can do this in person or in writing. In addition, we will allow you or your Authorized Appeal Representative, to see your files before and during the standard Internal Appeal process. If you do not understand English, we will help you with interpreter or translation services during the Internal Appeal process.

If you or your Authorized Appeal Representative files a standard Internal Appeal, we will not treat you differently or unfairly during or after the process. Legal representatives of a deceased Member’s estate can be included as parties to a standard Internal Appeal.

When will a Standard Internal Appeal Decision be made?

CeltiCare Health will give you an answer and send you and your Authorized Appeal Representative a notice within 20 days from the date CeltiCare Health received your written or oral request for a first level standard Internal Appeal unless:

  • You or your Authorized Appeal Representative requests to extend the timeframe by up to 5 calendar days, or
  • CeltiCare Health requests to extend the timeframe up to 5 calendar days because:
    • The extension is in your best interest, and;
    • We need additional information that we believe, if received, will lead to approval of your request, and;
    • Such information is expected to be received within 5 calendar days.

Please note that CeltiCare Health can only take this extension one time, either during the first level or second level standard Internal Appeal review.

If you do not agree with CeltiCare Health taking an extension of 5 calendar days, you may file a Grievance.

We will notify you, and your Authorized Appeal Representative, in writing of our second level review decision. If you do not agree with that decision, you, or your Authorized Appeal Representative, can file an Appeal with the Board of Hearings as outlined in the decision letter and in your Member Handbook.

Continuing Services during a Standard Internal Appeal

During the first level standard Internal Appeal:

If your first level standard Internal Appeal involves a decision by CeltiCare Health to reduce or stop covering a service that was previously approved, you will automatically continue to receive those services if you or your Authorized Appeal Representative requests a standard Internal Appeal within 10 calendar days from the date you were notified about the Adverse Action. If you do not want to receive these Continuing Services while a standard Internal Appeal is pending, you must specifically tell us that you do not want to receive these services.

During the second level standard Internal Appeal:

In the same way, if your second level standard Internal Appeal involves a decision by CeltiCare Health to reduce or stop covering a service that was previously approved, you will automatically continue to receive those services, if you request a second level standard Internal Appeal within 10 calendar days from receiving your first level standard Internal Appeal resolution notice. If you do not want to receive these Continuing Services while a standard Internal Appeal is pending, you must specifically tell us that you do not want to receive these services.

For both levels of standard Internal Appeal, continued coverage applies only to those services that were approved at the time they began and were not terminated because benefit coverage was exhausted.

How to Request an Expedited (fast) Internal Appeal?

If you or your Authorized Appeal Representative, or your Provider feel that taking the time for a Standard Internal Appeal could seriously jeopardize your life, health, or your ability to get, maintain or regain maximum function, an Expedited (fast) Internal Appeal may be requested.

Submit the request for the Expedited (fast) Internal Appeal the same way you submit for a Standard Internal Appeal to CeltiCare Health for non-Behavioral Health, Internal Appeals. It can be filed orally By calling Member Services; or in writing by you, your Authorized Appeal Representative, and/or your Provider. CeltiCare Health will process the Expedited (fast) Internal Appeal when a Provider is serving as your Authorized Appeal Representative even if CeltiCare Health has not received the Authorized Appeal Representative form. CeltiCare Health requires that the Provider submit a signed Authorized Appeal Representative form as documentation that you did authorize the Provider to file the Expedited (fast) Internal Appeal on your behalf; but the Expedited (fast) Internal Appeal will not be delayed while waiting for the form.

If being mailed or delivered, send to:

CeltiCare Health
Grievance and Appeal Coordinator – CarePlus
200 West Street, Suite 250
Waltham, MA 02451

For Behavioral Health Expedited (fast) Internal Appeals, call, mail, or fax to:

Cenpatico
Attn: Appeals Department
12515-8 Research Blvd, Suite 400
Austin, TX 78759
Phone: 1-866-896-5053, Fax: 1-866-714-7991

You, your Authorized Appeal Representative, or your healthcare Provider may request an Expedited (fast) Internal Appeal. If your Provider is not involved in your request for an Expedited (fast) Internal Appeal, then we have the right to determine whether or not to process the Internal Appeal as an Expedited (fast) Internal Appeal.

If your request does not qualify for an Expedited (fast) Internal Appeal, we will tell you, your Provider, and your Authorized Appeal Representative, in writing, about the decision. We will then process your Internal Appeal within the standard Internal Appeal 20 calendar-day timeframe. You, or your Authorized Appeal Representative, have the right to file a Grievance if you disagree with this decision not to expedite your Internal Appeal. CeltiCare Health will not take disciplinary action against a Provider who requests an Expedited (fast) Internal Appeal or supports a Member’s Expedited (fast) Internal Appeal request.

If you meet the qualifications for an Expedited (fast) Internal Appeal, CeltiCare Health will process your Appeal request and notify you of our decision orally and in writing, as quickly as your health requires, but not later than 72 hours from when we received your request. The timeframe can be extended by 14 calendar days as described below. We will notify you, your Authorized Appeal Representative, and your Provider in writing of the decision. We will also try to contact you by telephone to tell you about the decision.

If you are currently receiving Covered Services that are under your Expedited (fast) Internal Appeal, you may continue to receive services through the completion of the Expedited (fast) Internal Appeal process if the Expedited (fast) Internal Appeal was filed within 10 days of receiving CeltiCare Health’s Adverse Action notice, and the services you are appealing were previously authorized by CeltiCare Health.