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Medical Coverage: Your Rights

Prior Authorizations, Appeals, and Grievances

At Devoted, we always aim to offer our members excellent service and the care they need to stay healthy. But if you ever have problems with any part of your Devoted Health medical coverage, federal laws give you the right to:

  • Get a prior authorization (also called an organization determination) to find out if we’ll cover a specific treatment, device, or service
  • Make an appeal if you don’t agree with our decision about a prior authorization
  • File a complaint (grievance) related to a Devoted provider, your plan, or another part of your care

You can’t be disenrolled or get a penalty for doing any of these things — these are your rights as a member of our plan. Medicare has rules about how you can take these actions — and how we have to handle them when you do. That’s what the rest of this section is about.

Know that we’ll take your request seriously and deal with it fairly — not just because it’s the law (which it is), but because it’s the right thing to do. If you’d like to know the total number of prior authorizations, appeals, and complaints that have been filed with us, call 1-800-DEVOTED (1-800-336-6833), TTY 711.

You can have an authorized representative — like a trusted friend or family member — make some of these requests for you. Use this form to choose an authorized representative.

Get a Prior Authorization

This is a way to find out if we cover a certain medical service or item.

Examples of when you might need a prior authorization:

  • Your doctor recommends a specific type of surgery, but they’re not sure if we cover it
  • You need a device, like a new type of insulin pump

How do I ask for prior authorization? 
Usually, your provider will handle prior authorizations for you. But you or a representative can also request one by calling us at 1-800-DEVOTED (1-800-338-6833), TTY 711.

If you'd rather do it in writing, you or a representative can fill out the Prior Authorization Form.

View Prior Authorization Form

You can fax your completed form to 1-877-264-3872.

Or mail it to:
Devoted Health, Inc.
PO Box 540279
Waltham, MA 02454

Call us if you have any questions about prior authorizations. We can help walk you through the process.

What happens next?
Our team will make a careful decision based on your medical needs and Medicare’s guidelines. Then we’ll send you a letter explaining what we decided.

Normally, we’ll make a decision within 14 days of when we get your request. 

But if we find out (or your provider tells us) that waiting that long could harm your health, we’ll speed things up (expedite your request). In that case, we’ll let you know our decision within 72 hours.

Make an Appeal 

What happens if you don't agree with our decision?

You — or your provider or representative — have the right to file an appeal (request a reconsideration). It’s a way of asking us to rethink our decision. 

How do I make an appeal?
Call us — we can take all the information we need over the phone.

You can also send us a written appeal by mail or fax. Be sure to include your:

  • Name and address
  • Devoted Health Member ID (on your Devoted Health card)
  • Medicare number (on your Medicare card)

And, tell us why you're making the appeal. Let us know:

  • The type of treatment or service you're writing about
  • The date you asked us to approve the treatment or service (or the date you got it)
  • Why you disagree with our decision

If you have any other information that could help your case, include that too.

Once you're done, make a copy of everything for your own records.

You can fax your appeal to 1-877-264-3872.

Or mail it to:
Devoted Health, Inc.
PO Box 540279
Waltham, MA 02454

What’s the deadline for filing appeals?
You need to file your appeal within 60 days of the date you get our letter explaining our prior authorization decision.

What happens next?
It depends on your situation:

  • If you’re waiting to find out if you can get a treatment or service, we’ll send you a letter with our answer within 30 days. But if we find out that waiting that long could harm your health, we’ll speed things up (expedite your request). You’ll get an answer within 72 hours.
  • If you already got the treatment or service, you’ll get an answer within 60 days. 

What if I disagree with the answer to my appeal?
If we turn down your appeal, we’ll automatically send the information — your appeal and our response — to an outside group of experts. They’ll review it to see if we made the right decision.

This organization is called an Independent Review Entity (IRE) — it works for Medicare, not Devoted Health. Once the IRE makes a decision, you’ll get a letter in the mail.

File a Complaint (Grievance) 

Complaints are different from prior authorizations and appeals. They’re not about coverage problems.

Instead, complaints are about any other issues related to the care you get through your Devoted Health plan. Filing a complaint is a way of letting us know you’re having a problem with your care. We’ll do our best to fix it.

Examples of why you might file a complaint:

  • Your doctor didn’t give you the care you expected
  • It’s taking too long to get a treatment you need
  • You think your copays are too high
  • You’re having trouble understanding our materials or policies

How do I file a complaint?
The first step is to call us at 1-800-DEVOTED (1-800-338-6833), TTY 711. Hopefully, we can get the problem fixed right away on the phone.

You can also fax a written complaint to 1-877-264-3872.

Or mail it to:
Devoted Health, Inc.
PO Box 540279
Waltham, MA 02454

You can also file a complaint with Medicare directly. 
If you want to let Medicare know about problems you’re having with your Devoted Health plan, fill out the Medicare Complaint Form

What’s the deadline for filing complaints with Devoted?
Starting on the day you had the problem with your care, you have 60 days to file your complaint. So it’s a good idea to do it quickly.

What happens next?
We’ll look into your complaint and have a response for you within 30 days.