An appeal is a request for us to reconsider our original decision to deny or reduce services that you asked for. It is also referred to as a reconsideration or redetermination.
You can appeal if CommuniCare Advantage denies one of these:
If CommuniCare Advantage denies a service, you will be sent a letter, and that letter will explain your appeal rights. If you choose to appeal, you should file your appeal within 60 calendar days of the denial by following the appeal steps outlined in the letter and below. If you do not file your appeal within 60 days, it will be dismissed unless you can tell us why it was filed late and it meets certain criteria.
You can file your appeal in the following ways:
Coverage Determination Department
2181 E. Aurora Road
Twinsburg, OH 4487
You should include the following information with your appeal: your full name, subscriber ID number, the items or services for which you are requesting a reconsideration, the dates of service, and the reason why you are appealing)
You or your authorized representative can file the appeal, or a provider may file the appeal on your behalf. You can request a Fast appeal, if you think your health could be seriously harmed by waiting the standard timeframe for a decision.
For standard service requests (excluding pharmacy and Part B Drugs), we might need an additional 14 days to resolve it, and we will let you know in writing if this happens.
Once we make a decision, we will send the decision to you or your representative in writing. If we continue to deny your request, we will send your case file to Medicare’s Independent Review Organization in case you choose to file a second level appeal. The appeals process has five levels. If you disagree with the decision made at any of the levels, you can generally go to the next level. At each level, you will be given instructions in the decision letter on how to move to the next appeal level.
Last modified: September 4, 2020 at 5:47 am