Other important information and forms

Rights and responsibilities

These documents explain your rights and protections as a member of NaviCare HMO SNP and also explain what you can do if you think you are being treated unfairly or your rights are not being respected.

  • Medicare Advantage rights and responsibilities (coming soon)
    This document is for members who are enrolled in both Medicare and MassHealth Standard.
  • MassHealth-only rights and responsibilities (coming soon)
    This document is for members who are enrolled in MassHealth Standard but are not enrolled in Medicare.
 

Disenrollment rights 

Ending your membership in our plan may be voluntary (your own choice) or involuntary (not your own choice). Whether leaving the plan is your choice or not, this document explains your coverage choices after you leave and the rules that apply. 

  • Medicare Advantage disenrollment rights (coming soon)
    This document is for members who are enrolled in both Medicare and MassHealth Standard.
  • MassHealth-only disenrollment rights (coming soon)
    This document is for members who are enrolled in MassHealth Standard but are not enrolled in Medicare.
 

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 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 decided not to continue, you would be notified by letter at least 60 days before your coverage ended. The letter would explain your options.

Appeals, grievances and exceptions information

This document explains the process for filing an appeal or grievance and how to request an exception to the formulary.

  • Medicare Advantage appeals, grievances and exceptions (pdf, 49 KB)
    This document is for members who are enrolled in both Medicare and MassHealth Standard.
  • MassHealth-only appeals, grievances and exceptions (coming soon)
    This document is for members who are enrolled in MassHealth Standard but are not enrolled in Medicare.

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 1-877-255-7108 (TDD/TTY: 1-877-795-6526), seven days a week from 8 a.m. to 8 p.m.

FCHP's other options for older adults

 

NaviCare HMO brochures

Other important forms

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, 63 KB)
This form may be used to appoint someone to handle a grievance, coverage determination, or in dealing 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).

Notice of Privacy Practices (pdf, 33 KB)
This document is Fallon Community Health Plan’s notice of privacy practices.

Personal Representative Authorization Form - Disclosing 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 (pdf, 72 KB)
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, 34 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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