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Member Appeals & Grievances

What is an appeal?

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:

  • Your request to get a healthcare service, item, or drug you think should be covered, provided, or continued
  • Your request for payment for a healthcare service, item, or drug you already got
  • Your request to change the amount you pay for a healthcare service, item, or drug

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:

For Medicare Part A (facility) and Part B (medical services and equipment) benefits:

Call Member Services:

  • If you live in one of our nursing facilities (I-SNP),
    call (855) 969-5861
  • If you are part of the chronic care plan (C-SNP),
    call (855) 969-5869

OR write to us at:

CommuniCare Advantage Appeals and Grievances

PO Box 94138
Lubbock, TX 79493-4138

For Medicare Part D (Pharmacy) services:

Call Elixir

  • If you live in one of our nursing facilities (I-SNP),
    call (833) 697-8516
  • If you are part of the chronic care plan (C-SNP),
    call (833) 685-5387

OR write to us at:

Elixir

Coverage Determination Department

2181 E. Aurora Road
Twinsburg, OH 4487

OR Fax to:

(877) 503-7231

Online by going to:

envision.promptpa.com

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.

  • Expedited (Fast) request: 72 hours
  • Standard service request for Part A and Part B services: 30 calendar days (7 days for a Part B Drug reconsideration)
  • Payment request: 60 calendar days
  • Pharmacy/Part D benefits: 7 calendar days
  • Pharmacy/Part D payment: 14 calendar days

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.

A grievance is a complaint about any aspect of the operations, activities, or behavior of your health plan, prescription drug plan, or your health care providers.

Examples of grievances include:

  • Problems getting an appointment, or having to wait a long time for an appointment
  • Disrespectful or rude behavior by doctors or staff, or by CommuniCare Advantage staff
  • Complaints about the quality of care you have received from a provider
  • Difficulty contacting CommuniCare Advantage by phone

Grievances should be filed within 60 calendar days of the incident happening. If more than 60 days have passed since the incident, the grievance will 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:
For Medicare Part A (Facility), Part B (medical service and equipment) and Part D (Prescription Drug) benefits:

1) Call Member services.

  • If you live in one of our nursing facilities (I-SNP), call 855-969-5861
  • If you are part of the chronic conditions care plan (C-SNP), call 855-969-5869

2) Or write to us at:
CommuniCare Advantage Appeals and Grievances
4675 Cornell Road, Suite 162
Cincinnati, OH 45241

3) Or fax your complaint to:
CommuniCare Advantage Appeals and Grievances
513-605-6830

4) Contact Medicare at 1-800-MEDICARE (1-800-633-4227) or TTY 1-877-486-2048

5) For Quality of Care grievances, you may file a complaint with the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC_QIO) in your area.

  • Livanta QIO in Indiana and Ohio:
    Call: 888-524-9900 or TTY 888-985-8775
    Write: Livanta LLC
    BFCC-QIO
    10820 Guilford Road, Suite 202
    Annapolis Junction, MD 20701-1105
  • Livanta QIO in Maryland:
    Call: 888-396-4646 or TTY 888-985-2660
    Write: Livanta LLC
    BFCC-QIO
    10820 Guilford Road, Suite 202
    Annapolis Junction, MD 20701-1105

You should include the following information when you file a grievance: your full name, subscriber ID number, a description of what your complaint is about including provider names and dates of service (if applicable), and a contact number where you may be reached for more information. Your or your authorized representative may file the grievance. We must have a signed Appointment of Representative form on file in order to speak with someone other than the member or POA.

Expedited: 24 hours
Standard: 30 calendar days

For standard grievances, we might need an additional 14 days to resolve it, and we will let you know in writing if this happens.

Once we are able to research your grievance, we will send a resolution letter to you or your representative in writing.

For more information about the Appeals process, please refer to your Evidence of Coverage booklet

Last modified: October 1, 2021 at 4:23 am

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