Appeal Process FAQ | Overview
ACO Patient Appeals FAQs
Despite our best efforts, patients and their families may experience issues around care in Boston Children’s ACO and want to submit a grievance through our ACO appeals process. We encourage you to talk to your doctor or primary care practice first to see if they can help you. However, if the issue is about receiving care from another doctor, delayed access or denial of care that is not based on your insurance and you do not feel you can resolve the issue with your doctor, please call 919-617-1153 to work with an ACO representative to report and resolve your issue.
I received a letter from Boston Children’s Hospital and I do not know what it says
You may have heard about the ACO Patient Appeals program from your doctor or from a letter, you received in the mail from Boston Children’s Hospital. The appeals program is a way to file your ACO related grievance.
Your doctor is part of a group of primary care offices that work with Boston Children’s Hospital to improve healthcare and help patients access more services, programs and resources within an Accountable Care Organization (ACO) called the Children’s Hospital Integrated Care Organization (CHICO). ACOs are part of federal and state healthcare laws. Appeals or grievances are complaints you might have about timeliness of care or access to care in the ACO.
Can I continue to see my primary care doctor?
This letter and program will not change your primary care doctor, access to Boston Children’s Hospital, access to other doctors outside of Boston Children’s Hospital, nor your insurance coverage. All of your care will remain the same. If you do not have a grievance, you do not need to take any action.
What is a grievance/appeal?
A grievance or appeal is a patient complaint or issue that you believe can be resolved by using this process. Grievances/appeals do not apply to already resolved issues.
What do I need to do once I receive this letter?
You do not need to do anything after receiving this letter. This letter only provides information on who to contact if you have an issue at your doctor’s office that you cannot sort out in the office or over the phone. If you feel you are facing an issue around receiving care, accessing a specific service or seeing another doctor and you cannot resolve the issue with your doctor or practice, you can call 617-919-1153.
When would I need to call 617-919-1153?
If you are having a problem accessing medical services or seeing a different doctor because your primary care doctor has required additional paperwork or will not refer you to the doctor you want to see.
If you cannot access services or care because your insurance has denied the procedure, you will need to contact your insurance. We recommend calling your insurance provider to ask about your benefits before calling the ACO Appeals line. If it is an insurance issue, only your insurance provider can help.
What is an Accountable Care Organization?
Boston Children’s Accountable Care Organization (ACO) is a new program created out of state and federal healthcare laws. ACOs are organizations consisting of a group of health care providers that work together to coordinate patient care and enter into financial agreements that reward good care delivery outcome with insurance companies. If you were directed to this information by your primary care physician, his or her practice may be a participating provider of Boston Children’s ACO and your grievance may be addressed by this program.
What are examples of Accountable Care Organization grievance?
Some examples of issues to call about include:
- Timeliness of treatment or services
- Requests for referrals that you do not receive
- Ability to get the care you think you/your child needs
Grievances/appeals regarding your insurance coverage should be filed with your insurer. It is important to contact your insurer first, to understand your coverage and benefits.
How will I know if my issue is an ACO related issue?
You can call the ACO Appeals line 617-919-1153, MassHealth or the office of Patient Protections in the Health Policy Commission at any time and at any point in the process to see if your issue is an ACO issue and what steps you should take.
MassHealth: 1-800-841-2900 or TTY 1-800-497-4648
Massachusetts Office of Patient Protection: 800-436-7757
When can I call MassHealth or the Health Policy Commission?
As part of Massachusetts healthcare reform, MassHealth and the Health Policy Commission require the ACO to have an appeals line. If you have questions about this process and want to talk to someone outside of Boston Children’s, you can call MassHealth or the office of Patient Protections in the Health Policy Commission at any time and at any point in the process. They may be able to help explain the process to you or connect you to the right resources.
MassHealth: 1-800-841-2900 or TTY 1-800-497-4648
Massachusetts Office of Patient Protection: 800-436-7757
How do I file an appeal/grievance?
Please call 617-919-1153 and a representative will talk you through the process.
What happens when I file an ACO related issue?
You will call the ACO Appeals line 617-919-1153 and a representative will answer your call and collect basic information about the patient and the issue/grievance. You or someone acting on your behalf can call the ACO Appeals line. The representative will also work directly with interpreter services as well as your clinical team to address the grievance quickly.
We will respond to you in two (2) business days to let you know we received your grievance. We will give you a written answer to your grievance in thirty (30) calendar days. If your grievance involves urgent medical needs, we will give you a written answer in three (3) business days.
What if I am not happy with the results for my grievance?
You will need to call 617-919-1153 and discuss your issue. They will escalate your grievance to another reviewer. This reviewer will provide the final result of the grievance and talk with you about the results within 14 days.
Whom can I talk to about this process?
You can call 617-919-1153 and talk to a representative or you can ask your primary care doctor. You can also reach out to MassHealth or the office of Patient Protections in the Health Policy Commission at any time and at any point in the process.
MassHealth: 1-800-841-2900 or TTY 1-800-497-4648
Massachusetts Office of Patient Protection: 800-436-7757
I need this information in another language (Puede obtener esta información en español)
You can get this information in Spanish, or speak with someone about this information in other languages for free. Call 617-355-6279.
Puede obtener esta información en español, o hablar con alguien acerca de esta información en otros idiomas de forma gratuita. Llame al 617-355-6279.