AllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company
Section 10
Appeals and Grievances
Provider Grievances and
Administrative Appeals
10-1
Requesting an Administrative Appeal 10-1
Administrative Appeal Process 10-1
Appealing a Behavioral Health 10-2
Service Denial 10-2
Provider Audit Appeals 10-2
General Claims Audit Appeal Requests 10-2
Member Inquiries,
Complaints, and Grievances 10-2
Inquiries 10-2
Complaints and Grievances 10-2
Behavioral Health Inquiries and Grievances 10-4
Dental Services Inquiries and Grievances 10-4
Member Clinical Appeals 10-4
Expedited Clinical Appeals 10-4
Expedited External Review 10-4
Standard Clinical Appeals 10-5
Standard External Reviews 10-6
Access to Appeal File by Member or Member
Representative 10-6
Consumer Protection from Collections and Credit
Reporting During Appeals 10-7
Behavioral Health Appeals 10-7
Dental Services Appeals 10-7
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-1 2019-01 01
Section 10
Appeals and Grievances
Provider Grievances and
Administrative Appeals
Complaints regarding reimbursement, a specific claim
rejection, or any other provider issue should be reported
to AllWays Health Partners Provider Service.
• A grievance (or complaint) is a statement of
dissatisfaction with AllWays Health Partners’
actions or services.
• An appeal is a request for AllWays Health Partners to
reconsider an adverse action or denied claim submitted
with documentation supporting the request for
reconsideration.
Requesting an Administrative Appeal
As described in the Billing Guidelines Section of the
Provider Manual, providers can request a review and
possible adjustment of a previously processed claim
within 90 days of the Explanation of Payment (EOP)
date on which the original claim was processed. If the
provider is not satisfied with the outcome of the request,
an appeal can be submitted to AllWays Health Partners’
Appeals and Grievances Department.
An appeal is a request for reconsideration of a claim
denial by AllWays Health Partners. Appeal requests
must be submitted in writing within one of the
following timeframes:
• 90 days of receipt of the AllWays Health Partners
Explanation of Payment (EOP)
• 90 days of receipt of the EOP from another
insurance, when applicable
• 90 days of the date of the claims adjustment letter
The appeal must include additional, relevant information
and documentation to support the request. Requests
received beyond the 90-day appeal requests filing limit
will not be considered.
When submitting a provider appeal, please use the
Request for Claim Review Form.
Appeals may be submitted as follows:
Mail AllWays Health Partners
Appeals and Grievances Dept
399 Revolution Drive, Suite 810
Somerville, MA 02145
Fax 617-526-1980
Administrative Appeal Process
AllWays Health Partners has established a
comprehensive process to resolve provider grievances
and appeals:
• Appeals are reviewed by AllWays Health Partners’
Provider Appeals department. Appeal reviews are
completed within 30 calendar days from the date of
AllWays Health Partners’ receipt of the appeal
request and all supporting documentation.
• If the appeal request is approved, the claim is
adjusted, and the provider is notified via AllWays
Health Partners’ EOP (Providers should allow an
additional two weeks for the appealed claim to be
reprocessed and reflected in a future EOP).
• When the appeal request is denied, the provider is
notified in writing of the reason, and when
applicable, provided with instructions for filing an
external appeal.
• If additional information is needed to review the
appeal, the provider is notified in writing and allowed
an additional 60 days from the date of AllWays
Health Partners’ response letter to submit the required
information.
Providers who are notified in writing by AllWays
Health Partners of the administrative denial of an
authorization request due to the absence of supporting
documentation to establish medical necessity should
proceed as follows:
• If the service has not yet taken place, do not submit an
appeal. Instead, create a new request through
allwaysprovider.org with the supporting
documentation.
• If the service has already taken place and the claim
has denied, submit an appeal request with the
supporting documentation.
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-2 2019-01 01
Appealing a Behavioral Health
Service Denial
Optum is AllWays Health Partners’ Behavioral Health
Partner and is delegated all Behavioral Health (BH)
related matters, including grievances/complaints and
appeals. All BH related grievances/complaints and
appeals must be submitted to Optum directly.
For more information, please refer to the Behavioral
Health provider manual or contact Optum.
Provider Audit Appeals
General Claims Audit Appeal Requests
For claims audited and adjusted post-payment, if the
provider disagrees with the reason for the adjustments, a
letter of appeal or a completed AllWays Health Partners
Provider Audit Appeal Form may be submitted to
AllWays Health Partners’ Appeals Department within
90 days of the EOP.
The request must be accompanied by comprehensive
documentation to support the dispute of relevant
charges. To the extent that the provider fails to submit
evidence of why the adjustment is being disputed, the
provider will be notified of AllWays Health Partners’
inability to thoroughly review the request. The provider
can resubmit the appeal within the 90 days EOP
window. The appeal’s receipt date will be consistent
with the date AllWays Health Partners received the
additional documentation.
AllWays Health Partners will review the appeal and,
when appropriate, consult with AllWays Health Partners
clinicians or subject matter experts in the areas under
consideration. The appeal request will be processed
within 30 calendar days from AllWays Health Partners
’ receipt of all required documentation.
The appeal determination will be final. If the appeal
request is approved, AllWays Health Partners will
adjust the claims in question within 10 calendar days of
the provider’s notification of the final determination.
Member Inquiries,
Complaints,
and Grievances
AllWays Health Partners is committed to ensuring the
satisfaction of our members and the timely resolution of
all inquiries and reports of dissatisfaction by a member
(or his/her authorized representative) about any action
or inaction by AllWays Health Partners or a health care
provider. AllWays Health Partners provides processes
for members that allow for the adequate and timely
resolution of inquiries and grievances/complaints.
Inquiries
An inquiry is any oral or written question made by, or on
behalf of, a member to AllWays Health Partners or its
designees that is not the subject of an adverse determination
or adverse action, and that does not express dissatisfaction
about AllWays Health Partners or its operations,
processes, services, benefits, or providers.
Upon receipt of an inquiry, AllWays Health Partners’
Customer Service Representative will document the
matter and, to the extent possible, attempt to resolve it at
the time of the inquiry.
Complaints and Grievances
While grievances are typically reported by members,
AllWays Health Partners will investigate all reported
incidents when there are member care and other
concerns. Possible subjects for grievances include, but
are not limited to:
• Quality of Care—A member’s perception of poor
provision of clinical care and/or treatment by medical
staff
• Access—A member reports of inability to access
needed care in accordance with wait-time standards or
in a manner that met the member’s perceived needs
o Access is defined as the extent to which a
member can obtain services (telephone access
and scheduling an appointment) at the time they
are needed. It can also include wait time to be
seen once the member arrives for a visit or
geographic access to a network provider
• Service/Administration—A member asserts that there
was a problem with interpersonal relationships, such
as rudeness on the part of a provider or AllWays
Health Partners staff person and/or deficiencies in
what would generally be considered good customer
or patient service
• Billing and Financial—A member’s dispute of
responsibility for rendered services, cost-sharing
amounts, or other financial obligations
• Provider’s Facility—A member asserts the provider’s
facility was inadequate, including, but not limited to
cleanliness of waiting room, restrooms, and overall
physical access to the premises
• Privacy Violation—A member reports that his or her
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-3 2019-01 01
protected health information (PHI) was released,
misdirected, or violated by AllWays Health Partners
or a provider
• Member Rights—A member reports that his or her
member rights were violated by AllWays Health
Partners or a provider. This can include a member’s
allegation that AllWays Health Partners is not
providing behavioral health services in the same way
that physical health services are provided, as required
by Mental Health Parity Laws
Grievances are researched and resolved as expeditiously
as warranted, but no later than 30 calendar days from
the verbal or written notice of the grievance.
Members may designate a representative to act on their
behalf and such representative is granted all the rights of
a member with respect to the grievance process, unless
limited in writing by the member, law, or judicial order.
The member must complete and return a signed and
dated Designation of Appeal or Grievance
Representative Form prior to the deadline for resolving
the grievance. If the signed form is not returned,
communication can only take place with the member.
AllWays Health Partners ensures that any parties
involved in the resolution of inquiries, grievances, and
any subsequent corrective actions have the necessary
knowledge, skills, training, credentials, and authority to
make and implement sound decisions and that they have
not been involved in any previous level of review or
decision-making. Members or their representatives are
provided with a reasonable opportunity to present
evidence and allegations of fact or law, in person as well as
in writing.
A member may file a complaint or grievance by telephone,
fax, letter, or in person. AllWays Health Partners
Customer Service Professionals provide reasonable
assistance, including, but not limited to, providing full
interpreter services, toll-free numbers (including
TTY/TTD access), explaining the grievance or appeal
process, and assisting with the completion of any forms.
All grievances are logged and when conveyed verbally
to a Customer Service Professional, the process includes
a reduction of the oral grievance to writing.
Received grievances are referred to the Appeals and
Grievances Coordinator who will send the member or
member’s representative an acknowledgment letter
within one business day. The letter instructs the member
or member’s representative to sign and return a copy of
the letter to AllWays Health Partners prior to the
deadline for resolving the grievance. However, the
investigation of a member’s grievance is not postponed
pending return the signed letter. The member or
authorized representative’s signature simply
acknowledges that AllWays Health Partners has
captured the details of the grievance correctly.
An AllWays Health Partners health care professional
with the appropriate clinical expertise in treating the
medical condition, performing the procedure or
providing treatment that is the subject of a grievance
will make an initial assessment as to the clinical
urgency of the situation and establish a resolution time
frame accordingly if the grievance involves:
• The denial of a member or member’s
representative’s request that an internal appeal be
expedited
• Any clinical issue
The AllWays Health Partners Appeal Committee will
resolve a grievance if the subject of the grievance
involves:
• The denial of payment for services received because
of failure to follow prior authorization/referral
procedures
• The denial of a member or member representative’s
request for an internal appeal because the request
was not made in a timely fashion
• The denial of coverage for non-covered services
• The denial of coverage for services with benefit
limitations
• Reduction in AllWays Health Partners Provider
payment due to copayments, deductibles, or
coinsurance
When the subject matter involves the act or omission on
the part of an AllWays Health Partners employee,
resolution is made by the employee’s department, unless
circumstances warrant as determined by the Appeals
and Grievance Manager, that resolution should be made
external to the employee’s department.
For grievances involving non-clinically related actions
or omissions of a provider, the Grievance Coordinator
requests assistance from the provider to investigate the
grievance. Network providers’ adherence to the
grievance process is monitored regularly to identify
training and other interventions.
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-4 2019-01 01
For grievances/complaints concerning a provider, the
nature of the complaint determines whether the matter is
addressed directly with the clinician or with the site
administrator. In either case, the provider is contacted to
discuss the matter and asked for a written response
stating the facts, including supporting documentation
when appropriate. To allow timely completion of the
review of all relevant information within the specified
time frame, a response from the provider is expected
within five business days unless otherwise agreed upon.
The response must address all identified concerns and
include corrective actions for each when applicable.
Upon receipt of the provider’s response and review of
all relevant information, a written response is sent to the
member containing the substance of the complaint, as
well as findings and actions taken in response, taking
into consideration the confidentiality rights of all
parties. At a minimum, the resolution will acknowledge
receipt of the grievance and that it has been
investigated. If the grievance resolution results in an
adverse action, the response letter will advise the
member of his or her right to appeal the decision.
Behavioral Health Inquiries and
Grievances
Management of all behavioral health–related inquiries and
grievances is delegated to AllWays Health Partners’
Behavioral Health Partner, Optum.
For more information, please see the Behavioral
Health Provider Manual or contact Optum.
Dental Services Inquiries and
Grievances
AllWays Health Partners delegates the grievance process
for routine dental services for certain Commercial/QHP
members to Delta Dental.
Please verify the member’s dental coverage with
AllWays Health Partners Customer Service Department.
Member Clinical Appeals
Expedited Clinical Appeals
AllWays Health Partners will provide an expedited
appeal process if it is believed that the member’s health,
life, or ability to regain maximum function may be put
at risk by waiting 30 calendar days for a standard appeal
decision. AllWays Health Partners will grant a request
for an expedited appeal, unless the request is not related
to the member’s health condition.
Members have the right to apply for an expedited
external review at the same time a request for internal
expedited review is requested. (See “Commercial
Expedited External Review” section on how to submit
an external review.)
AllWays Health Partners will continue to authorize
disputed services during the formal appeal process if
those services had initially been authorized by AllWays
Health Partners, unless the member indicates that s/he
does not want to continue receiving services.
AllWays Health Partners will provide an expedited
appeal process under certain circumstances:
• When an appeal is submitted by or on behalf of a
member who is inpatient in a hospital, resolution
will be provided prior to the member’s discharge
from the hospital.
• When the treating provider certifies that the
requested service or equipment is medically
necessary and that there is a substantial and
immediate risk of serious harm should the service or
equipment not be provided pending the outcome of
the normal appeal process, resolution will be made
within 48 hours.
• When an expedited appeal is submitted by or on
behalf of a member with a terminal illness,
resolution will be provided within 72 hours and a
written response within five business days from the
receipt of the appeal.
• If the appeal for a member with a terminal illness is
upheld, the member or representative may request a
conference with a AllWays Health Partners medical
director. The conference should be scheduled within
10 calendar days of the notification of the
determination, or within 5 calendar days if the
treating provider has consulted with AllWays Health
Partners’ Chief Medical Officer or Medical Director
and it has been determined that the conference
should be at an earlier date. Decisions on expedited
appeals will be made within 72hours of receipt.
Expedited External Review
Members or their representatives can file an expedited
external appeal at the same time that they file an internal
expedited appeal or if they are dissatisfied with the
expedited internal appeal decision. A request must be
made to the Department of Health (DPH) Office of
Patient Protection (OPP) within four months after the
expedited internal appeal decision, but within two days
if they wish to receive continuing services without
liability.
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-5 2019-01 01
An application fee of $25.00, payable to the OPP, must
accompany the request. The application fee may be
waived if the OPP determines that payment of the fee
would result in an extreme financial hardship for the
member.
Members or their representative should also submit a
copy of AllWays Health Partners’ final adverse
determination letter along with the request. OPP will
complete the expedited appeal within 72 hours of
receipt.
Standard Clinical Appeals
A treating provider may file a clinical appeal on behalf
of a member for any decision made by AllWays Health
Partners to deny, terminate, modify, or suspend a
requested health care benefit based on failure to meet
medical necessity, appropriateness of health care
setting, or criteria for level of care or effectiveness of
care.
An appeal must be filed within 180 calendar days of
AllWays Health Partners’ decision to deny, terminate,
modify, or suspend a requested health care service.
In order to file an appeal on behalf of a member, or if an
individual other than the member or legal guardian
requests the appeal, AllWays Health Partners must be
provided with written authorization from the member
designating the provider as the appeal representative.
The Designation of Appeal Representative Form should
be used for this purpose. The member must complete
and return a signed and dated copy of this form prior to
the deadline for resolving the appeal. Failure to return
the signed form means communication can only take
place with the member. The appeal process will not be
held up pending receipt of the form.
When filing an appeal on behalf of a member, the
provider must identify the specific requested benefit that
AllWays Health Partners denied, terminated, modified,
or suspended, the original date of AllWays Health
Partners’ decision, and the reason(s) the decision should
be overturned. The Provider may request a peer-to-peer
discussion with the AllWays Health Partners medical
director involved in the Internal Appeal regarding these
matters.
Appeals may be filed by telephone, mail, fax, or in
person. AllWays Health Partners will send a written
acknowledgment of the appeal on behalf of a member,
along with a detailed notice of the appeal process,
within one business day of receiving the request.
An appeal will be conducted by a health care
professional that has the appropriate clinical expertise in
treating the medical condition, performing the
procedure, or providing the treatment that is the subject
of the Adverse Action, and who was not involved in the
original Adverse Action.
When an appeal is submitted by or on behalf of a
member with a terminal illness, resolution will be
provided within five business days of the request.
For a standard Internal Appeal resolution, AllWays
Health Partners will complete the appeal and contact the
provider within 30 calendar days with the outcome of
the review.
The time frame for a standard appeal may be extended
for up to 15 additional calendar days due to
circumstances beyond AllWays Health Partners’ control
and providing that the member or representative agree
to the extension.
The Appeal and Grievance Coordinator will make
reasonable efforts to provide oral notice to the
member/member representative within one business day
of the decision being made with a written notice to
follow within 30 days of receipt of the appeal.
AllWays Health Partners will continue to authorize
disputed services during the formal appeal process if
those services had initially been authorized by AllWays
Health Partners. Continued authorization will not,
however, be granted for services that were terminated
pursuant to the expiration of a defined benefit limit.
Providers, if acting in the capacity of an authorized
representative, may request that AllWays Health
Partners reconsider an appeal decision if the provider
has or will soon have additional clinical information that
was not available at the time the decision was made.
Upon a reconsideration request, AllWays Health
Partners will agree in writing to a new time period for
review. To initiate reconsideration, contact the Appeal
Coordinator.
Appeals may be filed by telephone, mail, fax, or in
person. AllWays Health Partners will send a written
acknowledgment of the appeal on behalf of a member,
along with a detailed notice of the appeal process within
one business day of receiving the request.
An appeal will be conducted by a health care
professional that has the appropriate clinical expertise in
treating the medical condition, performing the
procedure, or providing the treatment that is the subject
of the Adverse Action, and who was not involved in the
original Adverse Action.
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-6 2019-01 01
When an appeal is submitted by or on behalf of a
member with a terminal illness, resolution will be
provided within five business days of the request.
For a standard Internal Appeal resolution, AllWays
Health Partners will complete the appeal and contact the
provider within 30 calendar days with the outcome of
the review.
The time frame for a standard appeal may be extended
for up to 15 additional calendar days due to
circumstances beyond AllWays Health Partners’ control
and providing that the member or representative agree
to the extension.
The Appeals and Grievances Coordinator will make
reasonable efforts to provide oral notice to the
member/member representative within one business day
of the decision being made with a written notice to
follow within 30 days of receipt of the appeal.
AllWays Health Partners will continue to authorize
disputed services during the formal appeal process if
those services had initially been authorized by AllWays
Health Partners. Continued authorization will not,
however, be granted for services that were terminated
pursuant to the expiration of a defined benefit limit.
Providers, if acting in the capacity of an authorized
representative, may request that AllWays Health
Partners reconsider an appeal decision if the provider
has or will soon have additional clinical information that
was not available at the time the decision was made.
Upon a reconsideration request, AllWays Health
Partners will agree in writing to a new time period for
review. To initiate reconsideration, contact the Appeal
Coordinator.
Contact Information
AllWays Health Partners
Appeals and Grievances Department
399 Revolution Drive, Suite 810
Somerville, MA 02145
Phone: 855-444-4647
Fax: 617-526-1980
Standard External Reviews
As part of every written appeal decision that upholds an
original decision to deny, terminate, modify, or suspend
a requested health care benefit, a member or authorized
representative is informed in detail of additional appeal
options and the procedures for accessing those options.
Members (or their authorized representatives) have the
option of requesting an external appeal with the Office
of Patient Protection (OPP) if they are not satisfied with
the final outcome of AllWays Health Partners’ appeal
process.
In order to activate the external review process with the
Office of Patient Protection you will be asked to:
• Complete and submit the Request for Independent
External Review of a Health Insurance Grievance
form (enclosed with the Notice of Decision from
AllWays Health Partners) to the Office of Patient
Protection within four months of receiving AllWays
Health Partners’ written decision on your appeal
• Submit a $25 fee to the Office of Patient Protection
along with your request. The Office of Patient
Protection may waive the fee in circumstances of
financial hardship
• Submit a copy of AllWays Health Partners’ final
adverse determination letter to the Office of Patient
Protection along with your request
OPP will complete the appeal within 45 days of receipt
of the appeal.
Contact Information
AllWays Health Partners
Appeals and Grievance Department
399 Revolution Drive, Suite 810
Somerville, MA 02145
Phone: 855-444-4647
Fax: 617-526-1980
To initiate an external review, contact:
Office of Patient Protection (OPP)
Health Policy Commission
50 Milk Street, 8th Floor
Boston, MA 02109
Phone: 800-436-7757
Fax: 617-624-5046
Access to Appeal File by Member or
Member Representative
Members or their representative have the right to
receive a copy of all documentation used in the
processing of their appeal, free of charge.
Limitations may be imposed, only if, in the judgment of
a licensed health care professional, the access requested
is reasonably likely to endanger the life or physical safety
of the individual or another person.
The member (or an authorized representative) must
submit their request in writing to AllWays Health
Partners and it will be processed by the Appeal and
AllWays Health Partners—Provider Manual 10 – Appeals and Grievances
www.allwaysprovider.org 10-7 2019-01 01
Grievance Coordinator, in consultation as necessary
with the Compliance Office.
Requests for access to appeal files will be processed as
quickly as possible, taking into consideration the
member’s condition, the subject of the appeal, and the
time frames for further appeals.
Continuation of Ongoing Services During Appeal
If the internal appeal filed concerns the denial, modification,
or termination of an AllWays Health Partners covered
service that the member is receiving at the time of the
adverse action, the member has the right to continue his or
her benefits through the conclusion of the appeals
process. Continued authorization will not, however, be
granted for services that were terminated pursuant to the
expiration of a defined benefit limit.
If the internal appeal filed concerns the denial, modification,
or termination of a non-covered service that the member is
receiving, and AllWays Health Partners does not reverse
the adverse action, the member may be liable for
payment of the service.
Notification of Decision
If AllWays Health Partners does not act upon an appeal
within the required timeframe, or an otherwise agreed
upon extension, the appeal will be decided in the
member’s favor. Any extension deemed necessary to
complete review of an appeal must be authorized by
mutual written agreement between the member (or an
authorized representative) and AllWays Health Partners.
Reconsideration of Appeal Decision
Providers, if acting in the capacity of an authorized
representative, may request that AllWays Health
Partners reconsider an appeal decision if the provider
has or will soon have additional clinical information
that was not available at the time the decision was made.
Upon a reconsideration request, AllWays Health Partners
will agree in writing to a new time period for review. To
initiate reconsideration, contact the individual identified in
the decision letter upon receipt.
Consumer Protection from Collections
and Credit Reporting During Appeals
Effective 7/1/15, Massachusetts Law requires health
care providers (and their agents) to abstain from
reporting a member’s medical debt to a consumer credit
reporting agency or sending members to collection
agencies or debt collectors while an internal or external
appeal is on-going. This consumer protection also
extends for 30 days following the resolution of the
internal or external appeal.
Behavioral Health Appeals
Management for all behavioral health related appeals
is delegated to AllWays Health Partners’ Behavioral
Health Partner, Optum.
For more information, please see the Behavioral
Health Provider Manual or contact Optum.
Dental Services Appeals
AllWays Health Partners delegates the internal
grievance/appeal process for routine dental services for
some Commercial/QHP members to Delta Dental.
Please verify the member’s dental coverage with
AllWays Health Partners’ Customer Service
Department.
