Grievance and Appeal Process for Community y Más (HMO C-SNP), a Medicare Plan

How to File a Grievance?

Medicare Grievance Process

As a member of Community y Más, we encourage you to please let us know if you have, concerns or problems related to your coverage or the care you receive. Community y Más Member Services staff are always ready to help you solve any problems you have about your care. Our Member Services 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 Community y Más Member Services Department toll free at 1-800-232-3133 (TTY 1-855-266-4584). Community y Más 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 Community y Más at the following address:

Community y Más
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 Community y Más 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 Community y Más receiving your grievance. For questions about the status of your grievance, call the Member Services Department at 1-800-232-3133 (TTY  1-855-266-4584). Community y Más representatives are available 24 hours a day, 7 days a week, including holidays. For additional information regarding the Community y Más grievance process, please see the Member Handbook.

Grievance Process

There are two kinds of grievances:

Fast Grievance (24 hours): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with Community y Más' 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. Community y Más 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. Community y Más 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 Community y Más, 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: 

Community y Más
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, you, your doctor, or authorized representative can call, write, or fax us.

• You can call us at: 1-800-323-3133. TTY: 1-855-266-4584.

• You can write us at:

  Community y Más
  2420 Fenton Street
  Chula Vista, CA 91914

   

• You can fax us at: 619-476-3834

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 1-800-323-3133, TTY users should call 1-855-266-4584 or fax us at 619-476-3834.
• 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.

Medicare Appeals

As a member, you can file an appeal if Community y Más 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 Community y Más. 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:

Community y Más
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 Community y Más 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  Community y Más receiving your appeal.

For additional information regarding Community y Más' 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 Community y Más, contact the Member Services Department at 1-800-3232-3133 (TTY  1-855-266-4584). Community y Más 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. Community y Más 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, Community y Más will automatically give you a fast appeal.

If you or your appointed representative asks for a fast appeal without support from a doctor, Community y Más 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 Community y Más 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 Community y Más 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.

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/

Last Website Update 12/29/2023
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