Prior Authorization

Appealing Prior Authorization Decisions

Medical:

If you have submitted a prior authorization request for a procedure or service and it is denied, you or the member may request an appeal. If you request an appeal on a member’s behalf, the member will be required to give written permission for you to act as their authorized appeal representative, which will require their signature on this form.

We recommend that you put the appeal in writing along with any additional information for us to consider and send it to us via fax at 617-897-0805 or by mail to:

Well Sense Health Plan
ATTN: Appeals and Grievances Department
529 Main Street, Suite 500
Charlestown, MA 02129

The member or the member’s authorized representative may also deliver a written appeal in person to either the address above or our office in Manchester, NH. A member or their authorized representative also has the option to file an appeal orally by calling the Member Services department at the number listed on the back of the member’s ID card.

Pharmacy:

If we deny a pharmacy prior authorization request, you or the member have the right to appeal the decision. If you or the member appeal this decision, please submit any additional information that you would like us to consider during the internal appeal process.

For more information on submitting an appeal, see the Provider Manual.