Grievance and Appeal Process for (HMO D-SNP), a Medicare Medi-Care Plan

Because you have Medicare and Medi-Cal (Medicaid), you have different processes that you can use to handle your grievances (complaints) or appeals. Medicare and Medi-Cal approved these processes. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you. If your problem is about a benefit covered by Medicare, then you should use the Medicare process. If your problem is about a benefit covered by Medi-Cal, then you should use the Medi-Cal process. Please call our Member Services Department at 1-888-244-4430 and we can help you decide whether to use the Medicare or the Medi-Cal process.

How to File a Grievance?

Medicare Grievance Process

As a member of CommuniCare Advantage, 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 Member Services staff are always ready to help you solve any problems you have about your care. Our Customer Service staff will work with you to resolve any complaint that you may have. You can file the grievance at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem.

What is a Grievance

A grievance is a complaint you make about us or one of our network providers or pharmacies. This includes a complaint about the quality of your care or the quality of service provided by your health plan. You or your appointed representative may file a grievance. You may file a grievance by contacting the CommuniCare Advantage Member Services Department toll free at 1-888-244-4430 (TTY 1-855-266-4584).  CommuniCare Advantage Plan representatives are available 24 hours a day, 7 days a week, including holidays. You may also opt to submit your grievance in a letter and send it directly to  CommuniCare Advantage Plan at the following address:

CommuniCare Advantage
Attention: Grievance & Appeals Supervisor
2420 Fenton Street
Chula Vista, CA 91914 

Or fax to (619) 476-3834

You will receive a written letter telling you that CommuniCare Advantage 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 Plan receiving your grievance. For questions about the status of your grievance, call Member Services Department at 1-888-244-4430 (TTY  1-855-266-4584). CommuniCare Advantage Plan representatives are available 24 hours a day, 7 days a week, including holidays. For additional information regarding CommuniCare Advantage grievance process, please see the Member Handbook.

Grievance Process

There are two kinds of grievances that you can request:

Fast Grievance (24 hours): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with CommuniCare Advantage 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 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 must respond to you as promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint. 

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

Livanta 
BFCC-QIO Program 
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
1-877-588-1123 
TTY: 1-855-887-6668 

CMS Part C Reconsideration
Form: CMS Part C Reconsideration Form

Livanta California Medicare Beneficiary Complaints Helpline: 1-877-588-1123, or TTY 1-855-887-6668.

Appointment of Representative

You have the option to appoint a representative to act on your behalf and request an organization / 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):

• Appointment of Representative Form (English)

• Appointment of Representative Form (Spanish)

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

CommuniCare Advantage 
Attention: Grievance & Appeals Supervisor
2420 Fenton Street
Chula Vista, CA 91914 

Or fax to (619) 476-3834 

How to File a Medicare Coverage Decision (Organization or Coverage Determination)

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

• You can call us at: 1-888-244-4430. TTY: 1-855-266-4584.

• You can fax us at: 619-476-3834.

• You can write us at:

CommuniCare Advantage
2420 Fenton Street
Chula Vista, CA 91914 

How long does it take to get a coverage decision?

Standard Coverage Decision

After you ask and we get all of the information we need, it usually takes 5 business days for us to make a decision unless your request is for a Medicare Part B prescription drug. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. If we do not give you our decision within 14 calendar days (or 72 hours for a Medicare Part B prescription drug), you can appeal.

Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed. We cannot take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

Fast Coverage Decision

If you need a response faster because of your health, ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours (or within 24 hours for a Medicare Part B prescription drug).

However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. The letter will explain why more time is needed. We cannot take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

Asking for a fast coverage decision:

• Start by calling or faxing to ask us to cover the care you want.
• You can call us at 1-888-244-4430, TTY users should call 1-855-266-4584 or fax us at 619-476-3834. For details on how to contact us, go to Chapter 2; Section A, page 14 of the Member Handbook.
• You can also have your doctor or your representative call us to request a fast coverage decision.

Rules for asking for a fast coverage decision:

You must meet the following two requirements to get a fast coverage decision:

• You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for care or an item you have already received.)
• You can get a fast coverage decision only if the standard 14-calendar day deadline (or 72 hour deadline for Medicare Part B prescription drugs) could cause serious harm to your health or hurt your ability to function.

If your doctor says that you need a fast coverage decision, we will automatically give you one.

• If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.
• If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter informing you. We will also use the standard 14 calendar day (or 72 hours deadline for Medicare Part B prescription drugs) deadline instead.
• This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.

The letter will also tell how you can fila a "fast complaint" about our decision to give you a standard coverage decision instead of a fast coverage decision. For more information about the process for making complaints, including fast complaints, see Section J on page 187.

Appeals

As a member, you can file an appeal if CommuniCare Advantage 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. You, your doctor, 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 decision (i.e., the date printed or written on the notice). You must send your appeal in writing to:

CommuniCare Advantage
Attention: Grievance & Appeals Supervisor
2420 Fenton Street
Chula Vista, CA 91914 

Or fax to (619) 476-3834

You should include your name, address, subscribe 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.

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

For additional information regarding CommuniCare Advantage  appeal process, please see the Member Handbook.

For questions about the status of your appeal, or to get information about the number of grievances, appeals and exceptions filed with CommuniCare Advantage Plan, contact the Member Services Department at 1-888-244-4430 (TTY  1-855-266-4584). CommuniCare Advantage Plan representatives are available 24 hours a day, 7 days a week, including holidays.

There are five levels of the appeal process:

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:  

Standard Appeal:  

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.

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 will give you a decision no later than 30 calendar days after we get your appeal. If we do not decide within 30 calendar days, your appeal automatically goes to Appeal Level 2.

Fast Appeal:  

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 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 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.

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 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 refer to the CommuniCare Advantage Member Handbook. 

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.

State Fair Hearing Process

The Department of Social Services administers a Fair Hearing process. You have a right to a State Fair Hearing if services that your doctor asked to have been denied or stopped. If you get a written notice denying health services, that notice will include a form for you to file a grievance with CHG. However, it is your right to ask for a State Fair Hearing with or without filing a grievance with us or waiting for a decision from us about your grievance. 

To be eligible for a State Fair Hearing, you must ask for it within 120 days of receiving our decision to deny or stop services. To ask for a hearing, call the Department of Social Services at 1-800-952-5253, TTY users should call 1-800-952-8349 or send a letter asking for the hearing to: 

California Department of Social Services 
State Hearings Division 
P.O. Box 944243, MS 19-17-37 
Sacramento, CA 94244-2430 

If you need help with asking for a State Fair Hearing, please call Member Services at 1-888-244-4430. If you are granted a State Fair Hearing, you may represent yourself or be represented by an authorized third party such as legal counsel, relative, friend or any other person.

Some grievances, due to their urgency, may be eligible for an Expedited State Hearing (ESH). For more information on expedited State Fair Hearing, please refer to the Member Handbook.

Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-244-4430 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site https//www.dmhc.ca.gov has complaint forms, IMR application forms and instructions online.

You are not required to participate in CHG’s grievance process before seeking an IMR of our decision to deny coverage of an experimental/ investigational therapy. 

An IMR is available in the following situations: 

1. (a) Your doctor has recommended a health care service as medically necessary, or 
(b) You have gotten urgent care or emergency services that a doctor determined was medically necessary, or 

(c) You have been seen by an in-plan doctor for the diagnosis or treatment of the health condition for which you seek independent review, without a provider recommendation in (a) above or urgent or emergency services in (b) above. The in-plan provider need not recommend the disputed health care service as a condition for the enrollee to be eligible for an IMR. The provider may be an out-of-plan provider. However, the plan will not have liability for payment of services unless required by the director for services determined from the IMR to be a medically necessary covered benefit or reasonable under the emergency or urgent medical circumstances; and 

2. The disputed health care service has been denied, modified, or delayed by CHG or one of its plan doctors, based in whole or in part on a decision that the health care service is not medically necessary; and 

3. You have filed a grievance with CHG and the disputed decision was upheld or the grievance remains unresolved after 30 calendar days. 

If your grievance is eligible for expedited review, you are not required to file a grievance with CHG before asking for an IMR. If there is an imminent and serious threat to the health of the enrollee, all necessary information and documents shall be delivered to an independent medical review organization within 24 hours of approval of the request for review. In addition, the DMHC may waive the requirement that you follow CHG’s grievance process in extraordinary and compelling cases. 

For cases that are not urgent, the IMR organization designated by DMHC will provide its determination within thirty (30) days of receipt of your application and supporting documents. For urgent cases involving an imminent and serious threat to your health, but not limited to severe pain, potential loss of life, limb or major bodily function; the IMR organization will provide its determination within three (3) calendar days of the receipt of the information. At the request of the experts, the deadline can be extended by up to three (3) calendar days if there is a delay in getting all needed documents. 

The IMR process is in addition to any other procedures or remedies that may be available to you. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan about the care that was requested. You pay no application or processing fees for an IMR. You have the right to provide information in support of your request. For more information about the IMR process or to ask for an application form, please call CHG’s Member Services at 1-888-244-4430. The hearing impaired may call Member Services through the California Relay Service at 1-(800) 735-2929.

Medicare Electronic Complaint Form

To download a blank copy of the Medicare Electronic Complaint Form,click https://www.medicare.gov/MedicareComplaintForm/home.aspx

You may also access additional information on how to file a complaint on Medicare’s website at https://www.medicare.gov/ 

Requesting information about Grievance and Appeals 

If you want to request data information about grievances and appeals, please call Member Services at 1-888-244-4430 for more information.

Disclaimers

CommuniCare Advantage (HMO D-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program.  Enrollment in CommuniCare Advantage depends on contract renewal.

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-244-4430 , TTY users should call 1-855-266-4584, 24 hours a day, 7 days a week. The call is free.

ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas disponibles sin cargo. Llame al 1-888-244-4430 (TTY: 1-855-266-4584). Las llamadas a estos números son gratuitas.

请注意：如果您说简体中文，可免费获得语言援助服务。请致电 1-888-244-4430 （听障专线：1-855-266-4584）。通话免费。

PANSININ: Kung nagsasalita kayo ng ibang wika, may mga paglingkod na pagtulong sa wika na maabot ninyo, na libre. Tawagan ang 1-888-244-4430 (TTY: 1-855-266-4584). Liber ang tawag na ito.

請注意：如果您說繁體中文，可免費獲得語言援助服務。請致電 1-888-244-4430 （聽障專線：1-855-266-4584）。通話免費。

CHÚ Ý: Nếu bạn nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, sẽ có sẵn cho bạn. Gọi số 1-888-244-4430 (TTY: 1-855-266-4584). Cuộc gọi được miễn phí.

1-888-244-4430 تنبيه: إذا كنت تتحدث اللغة العربية ، فأن خدمات المساعدة اللغوية متاحة لك بدون اي مقابل. إتصل بالرقم :

1-855-266-4584او الهاتف النصي :

كلا الرقمين متوفرين ٢٤ ساعة باليوم ٧ أيام بالاسبوع.

توجه: اگر به زبان فارسی صحبت می‌کنید، خدمات کمک زبانی، به صورت رایگان، در اختیار شماست. با 4430-244-888-1 (پیام‌نگار: 1-855-266-4584) تماس بگیرید. تماس با این شماره‌ها رایگان است.

Last Website Update 10/03/2023
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