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Provider Appeals & Grievances

Contracted Providers

If the denial code reflects the need for a correction, you must submit a corrected claim.

If the claim has been processed but you disagree with how the claim was processed, you may file a Payment Dispute Resolution (PDR) within 60 calendar days of the original payment. You may do this in the following ways:

In writing:

CommuniCare Advantage
Attn:  Claims
PO Box 94238
Lubbock, TX 79493

By phone:

ISNP Members: (855) 969-5861
CSNP Members: (855) 969-5869

If a provider is appealing a pre-service denial on behalf of the member, please send the appeal to:

CommuniCare Advantage
Attn: Appeals and Grievances
4675 Cornell Road, Suite 162
Cincinnati, OH 45241

Note: According to your provider contract, you are not allowed to bill the member for any monies beyond their copay or coinsurance on claims for covered services.

Non-Contracted Providers:

You may file an appeal in writing within 60 days of the original decision or payment. You should include the member’s name, address, subscriber ID number, reasons for appealing, and any evidence you wish to attach. You must also include the Waiver of Liability form, which releases our member from any financial obligation. If the Waiver of Liability form is not included and we are not able to obtain it from you, the appeal will be dismissed.

Appeals must be sent in writing to:

CommuniCare Advantage
Attn: Appeals and Grievances
4675 Cornell Road, Suite 162
Cincinnati, OH 45241

Last modified: 01/04/2022

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