Prior Authorizations, Appeals, and Grievances

At eternalHealth as our members’ forever partner in healthcare, we work tirelessly to serve our members. However, if there’s ever an issue relating to your eternalHealth coverage, you have the right to contact eternalHealth immediately so that we may address your concern. These member rights include the ability to:

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

You can not be disenrolled from your plan or receive a penalty for doing any of the aforementioned things – it is part of your rights as a member of our plan. Medicare has regulations in place about how you can take these actions, as well as how we have to handle the situation when you do. This next section will cover this topic.

eternalHealth will take any and all requests seriously and process them impartially as required by law and demonstrated in our commitment to your care and satisfaction.

If you are looking for further details regarding these processes as well as those relating to Quality of Care grievances, and extensions of coverage for example for a hospital/in-patient stay, your Explanation of Coverage (EOC) found on your member portal has detailed explanations, contact information, and further resources.

Get Prior Authorization

This is to find out if we’ll cover a certain medical service, item, or expense!

How do you ask for prior authorization?

Normally, your provider will handle this issue for you, but you or a representative can also request a prior authorization by contacting us at +1 (800) 680-4568.
If you would like to do it in writing, you or a representative can fill out the Prior Authorization Form.
You can fax or mail the completed form to the following address:

Fax Number: +1 (866) 347-8128

Mailing Address:
PO Box 661
Southborough, MA 01772

What happens next?

Based on your medical needs and Medicare guidelines, our team here at eternalHealth will make a careful decision. We will then send you a letter to detail our explanation and our decision. Expect up to 14 days for a decision to be made upon receival of your request. However, if we learn (or if your provider tells us) that waiting that long could harm your health, we’ll expedite your request and send a decision within 72 hours.

File 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 to be reconsidered.

You can send us a written appeal by mail or fax. You’ll need to include your name, address, eternalHealth ID number, and tell us why you’re making an appeal. In that statement, let us know the type of treatment or service you’re writing about, the date you asked for approval for said treatment or service (or the date you’ve received it), and why you disagree with our decision.

If you have any other supporting documents, please include that.

Don’t forget to keep a copy of everything for your own records!

Fax Number: +1 (866) 326-1073

Mailing Address:
PO Box 671
Southborough, MA 01772

If you have any questions, we’re just a phone call away: +1 (800) 680-4568

What’s the deadline to file an appeal?

You must submit an appeal within 60 days of the date that you get our letter explaining our prior authorization decision.

What’s the next step?

It depends on your situation!

  1. If you’re waiting to find out if you can receive a treatment or service, we’ll send you a letter within 30 days. However, if we find out that waiting can harm your health, we’ll send you an answer within 72 hours through an expedited request.
  2. If you have already received treatment or a service, you’ll receive an answer in 60 days.

What if I disagree with my appeal as well?

If we uphold our initial decision, meaning we do not reverse the initial determination, we will automatically send the information, which includes your appeal and our response, to an external group of experts. They’ll review the information to make sure we made the right decision. This organization is called an Independent Review Entity (IRE), and they work for Medicare. Once the IRE has made a decision, you’ll be informed via mail. Your Explanation of Coverage (EOC) document has details about the IRE and what we refer to as the “Level 2 Appeal Process”. If you have any questions about this or any other part of the process, feel free to give us a call.

File a Complaint (Grievance)

Complaints are different from the prior authorization and appeals. They’re not about your coverage rights. Instead, complaints are about other issues related to care that you receive from eternalHealth. Filing a complaint is a way of letting us know you’re having an issue with your care, and that’s something we take very seriously.

Examples of why you may file a complaint include:

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

How would I file a complaint?

To start, give us a call at +1 (800) 680-4568. We’ll try to resolve the issue right away on the phone. However, you can also fax or mail a written complaint to:

Fax Number: +1 (866) 326-8128

Mailing Address:
PO Box 671
Southborough, MA 01772

If you would like to submit a complaint directly to Medicare, you can call 1-800-MEDICARE (+1 (800) 633-4227). TTY users can call +1 (877) 486-2048. You may also submit a complaint online at: https://www.medicare.gov/my/medicare-complaint

What’s your deadline for filing complaints with eternalHealth?

You have 60 days to file a complaint, this 60 day period starts the day that you first have the issue the complaint is about. The sooner you file, the faster we can take the necessary steps to resolve the issue.

What happens next?

We’ll look into your complaint, and you’ll receive a response back from us within 30 days.

Appointment of Representative

You can always ask someone to act on your behalf when making one of these requests. If you want to, you can name another person to act for you as your “representative” to ask for coverage decisions to file an appeal. If you want a friend, relative, your doctor or other provider, or other person to be your representative, you can fill out the “Appointment of Representative” form. This form gives that permission to act on your behalf. It must be signed by you and by the person you would like to act on your behalf. You must give us a copy of the signed form. Appointment of Representative Form Download

This page is also available in: Español (Spanish)

Page Last Updated On: January 17, 2022