How to File a Part C Appeal or Grievance?

As a member of CommuniCare Advantage (HMO-SNP), we encourage you to please let us know if you have concerns or problems related to your coverage or the care you receive. CommuniCare Advantage (HMO-SNP) Member Services staff is always ready to help you solve any problems you have about your care. Our Member Services Staff will try to resolve any complaint that you might have over the phone. If we cannot resolve your complaint over the phone within 48 hours, it is referred to the Grievance and Appeals department for further review. We call this our Grievance and Appeals process.

A grievance is a type of complaint you make if you are dissatisfied with CommuniCare Advantage (HMO-SNP) or our contracted providers for reasons other than a coverage decision. Grievances do not involve problems related to approving or paying for Part D drugs. You or your appointed representative may file a grievance within 60 days of the event or incident. You may file a grievance by contacting the CommuniCare Advantage (HMO-SNP) Member Services Department toll free at 1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP) Plan representatives are available 24 hours a day, 7 days a week, including holidays. You may opt to submit your Grievance in a letter and send it directly to CommuniCare Advantage (HMO-SNP) Plan at the following address:

CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910

Or fax to (619) 425-5348

You will receive a written letter telling you that CommuniCare Advantage (HMO-SNP) Plan received your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of CommuniCare Advantage (HMO-SNP) Plan receiving your grievance.

For questions about the status of your grievance, call Member Services Department at 1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP) Plan representatives are available 24 hours a day, 7 days a week, including holidays.

For additional information regarding CommuniCare Advantage (HMO-SNP) grievance process, please see Section 4 of your EOC.

You have the option to appoint a representative to act on your behalf and request a coverage determination, formulary exception, grievance and/or an appeal.

You can name a relative, friend, advocate, doctor, or someone else to act for you. If you want to name someone to act on your behalf, you and the person you would like to act on your behalf must fill out the, "Appointment of Representative" form. When completed, this form allows this person legal permission to act as your authorized representative. Please click on the following link to access CMS' Appointment of Representative Form (Form CMS -1696);

• http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf

The completed form should be faxed, mailed, or delivered in person to:

CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910

Or fax to (619) 425-5348

There are two kinds of grievances that you can request:

Fast Grievance (24 hour): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with CommuniCare Advantage (HMO-SNP) decision not to give you a fast decision on a medical care issue, or if you disagree with our decision to take a time extension on an initial decision or appeal. CommuniCare Advantage (HMO-SNP) will respond to this type of grievance by telephone, within 24 hours from the time that we received your complaint and within three calendar days, you will receive a written letter.

Standard Grievance (30 days) is any other type of complaint. CommuniCare Advantage (HMO-SNP) must respond to you within as promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint. CommuniCare Advantage (HMO-SNP) may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

If you are concerned about the quality of care you received, you can also send your complaint to CommuniCare Advantage (HMO-SNP) Plan, the Quality Improvement Organization (QIO), an independent review organization, or both. The QIO is called Health Services Advisory Group (HSAG). Complaints to HSAG must be in writing to the following address:

CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910

Or fax to (619) 425-5348

HSAG California Medicare Beneficiary Complaints Helpline: 1-866-800-8749, or TDD Hearing Impaired 1-800-881-5980 Available 24 hours a day, seven days a week.

APPEALS

As a member, you can file an appeal if CommuniCare Advantage (HMO-SNP) Plan made a decision to not pay for, not approve, or stop a service you think should be covered or provided to you. This could include denials for drugs or involve payment for services (including co-payments and billing issues or reimbursement) you received or believe you should receive under the CommuniCare Advantage (HMO-SNP) Plan. You, your prescribing physician or other prescriber acting on your behalf and upon providing notice to you, or your appointed representative must file a written request for appeal within sixty (60) calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice).

You must send your appeal in writing to:

CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910

Via fax: 619-425-5348

You will receive a written letter telling you that CommuniCare Advantage (HMO-SNP) Plan received your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of CommuniCare Advantage (HMO-SNP) Plan receiving your grievance.

For additional information regarding CommuniCare Advantage (HMO-SNP) grievance process, please see Section 4 of your EOC.

For questions about the status of your appeal, or to obtain an aggregate number of grievances, appeals and exceptions filed with CommuniCare Advantage (HMO-SNP) Plan for our Medicare Advantage Special Needs Plan, contact the Member Services Department at 1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP) Plan representatives are available 24 hours a day, 7 days a week, including holidays.

Appeal Level 1: If we deny any part or your entire request to cover or pay for service you, your treating physician or your appointed representative may ask us to reconsider or “appeal” our decision. There are two kinds of appeals that you can file:

For care you have not yet received: You, a physician who is treating you and acting on your behalf and has provided notice to you, or another person you name (such as your lawyer or a family member) may ask for a standard appeal regarding medical care or services you have not yet received.

For a decision about medical care or services you have not yet received, we will give you a decision within 30 calendar days, but will make it sooner if your health condition requires. However, if you request, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision.

For a decision about payment for care or services you already received: You or another person you name (such as your lawyer or family member) may ask for a standard appeal. CommuniCare Advantage (HMO-SNP) will give you a decision no later than 60 days after we get your appeal. If we do not decide within 60 days, your appeal automatically goes to Appeal Level 2.

You, any doctor acting on your behalf or your representative can ask us to give a fast appeal for services or care you have not yet received. We will give you decision about your medical care within 72 hours after you or your doctor ask for it sooner if your health requires. If any doctor asks for a fast appeal for you, or supports you in asking for one, CommuniCare Advantage (HMO-SNP) will automatically give you a fast appeal.

If you or your appointed representative asks for a fast appeal without support from a doctor, CommuniCare Advantage (HMO-SNP) will review your request. If we do not grant your request for a fast appeal, we will send you a letter within three calendar days notifying you that we will make our decision within the standard timeframe of 30 calendar days. The letter will also tell you how to file a grievance if you disagree with our decision to deny your request for a fast appeal, and will explain that we will automatically give you a fast decision if you get a physician’s support for a fast appeal.

How do I file an Appeal with CommuniCare Advantage (HMO-SNP) Health Plan?

For a fast appeal, you, your doctor, or your appointed representative should contact Member Services by telephone at 1-888-244-4430 (TTY 1-800-735-2929). CommuniCare Advantage (HMO-SNP) Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

For a standard appeal you, your treating physician, or appointed representative should mail, fax or deliver your written appeal to:

CommuniCare Advantage (HMO-SNP)
Attention: Grievance & Appeals Coordinator
740 Bay Boulevard
Chula Vista, CA 91910

Via fax: 619-425-5348

You should include your name, address, subscriber ID number, reason for appealing and any evidence that you wish to attach. You may include supporting medical records, doctors’ letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person to the fax number or address above.

Appeal Level 2: If we deny any part of your first appeal, your appeal automatically goes on to Appeal Level 2 where an independent review organization (IRE) will review your case. The independent review organization has no connection to CommuniCare Advantage (HMO-SNP) Health Plan. We will tell you in writing that your appeal has been sent to this organization for review. For complete details and further explanation of the appeal process, please review Section 5 of the CommuniCare Advantage (HMO-SNP) Medicare Advantage Special Needs Plan Evidence of Coverage.

Appeal Level 3: If the organization that reviews your case in Appeal Level 2 does not rule completely in your favor, you or your appointed representative may ask for a review by an administrative law judge in writing within 60 days after the date you were notified of the decision made at Appeal Level 2.

Appeal Level 4: If you get a denial at Appeal Level 3, you or your appointed representative can request review by filing a written request with the Medicare Appeals Council. The letter that you get from the administrative law judge will tell you how to contact the Council.

Appeal Level 5: To request a judicial review of your case, you must file a civil action in a United States District Court. The letter you get from Medicare Appeal Council in Appeal Level 4 will tell you how to request this review.