Other important information and forms
Rights and responsibilities
Below you can find information that explains your rights and protections as a member of NaviCare HMO SNP or NaviCare SCO and also explain what you can do if you think you are being treated unfairly or your rights are not being respected.
- For members who are enrolled in NaviCare HMO SNP (have both Medicare and MassHealth Standard), you can find information about your rights and responsibilities in your Evidence of Coverage (coming soon, pdf) in Chapter 8. Your rights and responsibilities.
Potential for contract termination
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, plans decide whether to continue for another year. If NaviCare HMO SNP leaves the program, you will not lose your Medicare nor MassHealth Standard coverage (provided that you continue to meet the eligibility requirements for MassHealth). If NaviCare HMO SNP decided not to continue, you would be notified by letter at least 90 days before your coverage ended. The letter would explain your options.
Appeals, grievances and exceptions information
These documents explain the process for filing an appeal or grievance and, if applicable, how to request an exception to the formulary.
NaviCare HMO SNP appeals, grievances and exceptions for Medicare Part D (H9001_N_2011_172 CMSApproved 06152011, pdf)
This document explains the process for filing an appeal or grievance for drugs covered under Medicare Part D, and how to request an exception to the formulary as a NaviCare HMO SNP member. You can also initiate a Medicare Part D appeal using our online form.
NaviCare HMO SNP appeals and grievances (non Part D) (H9001_N_2011_10 CMSApproved 03172011, pdf)
This document explains the process for filing an appeal or grievance for all other issues not related to Medicare Part D as a NaviCare HMO SNP member.
You have the right to get a summary of information about the appeals and grievances that members have filed against our Plan in the past. To get this information, call us at 1-877-700-6996 (TDD/TTY:
1-877-795-6526), Monday through Friday from 8 a.m. to 8 p.m. (From October 15 through February 14, we're available seven days a week.)
You may also use Medicare's complaint form that is available online at Medicare.gov.
NaviCare brochures
Other important information and forms
2012 Medicare Plan rankings
The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing illness, ratings from patients, patient safety, drug pricing and customer service). The information in this document is an overall plan rating of our plan's performance.
Fallon Community Health Plan - CY 2012 Medicare Plan Ratings (H9001_2012_720_299 File&Use 10182011, pdf)
Fallon Community Health Plan - Evaluaciones de Medicare del Plan para el año actual 2012 (H9001_2012_720_299SP File&Use 10182011, pdf)
Request for Medicare prescription drug coverage determination form (pdf)
Use this form for you to request an exception or coverage determination. You can also access an online version of this form.
Medicare Part D coverage determination request form (pdf)
The provider who prescribes your drugs may use this form to request an exception or coverage determination. You can also access an online version of this form
Request for redetermination of Medicare prescription drug denial (pdf)
Use this form to request a redetermination of a decision if coverage for a prescription was denied.
Prior authorization form (pdf, 70 KB)
This form may be filled out by the provider who prescribes your drugs that require prior authorization.
CMS' Appointment of Representative form (pdf, 68 KB)
This form may be used to appoint someone to handle a grievance or coverage determination, or to deal with any level of the appeal process.
Amendment Request for Personal Information form (pdf, 36 KB)
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.
Authorization for Release of Personal Information form (pdf, 36 KB)
Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).
Veteran’s Office Authorization for Release of Personal Information form (pdf, 47 KB)
Allow a veteran’s office to receive your personal information from FCHP.
Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Community Health Plan’s notice of privacy practices.
Personal Representative Authorization Form - Accessing Personal Information (pdf, 56 KB)
Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.
Personal Representative Authorization Form – Filing an Appeal (H9001_2011_735_11 CMSApproved 05022011, pdf)
This form is to be used by NaviCare members to authorize someone to file an appeal on the member’s behalf. Note: This form automatically expires after a year.
Request for an Accounting of Disclosures of Personal Information form (pdf, 36 KB)
Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.
Restriction form (pdf, 36 KB)
Request a limit on how we use or share your personal information.
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H9001_N_2012_15_r1 Pending CMS Approval
The information on this page was last updated on 12/6/2011.