Medicare Part C and Part D Grievances, Coverage Decisions and Appeals Summary


Topic
Details
Instructions for
Filing a Grievance or Complaint about Medical Care or Part D Prescription Drugs

Located in Chapter 9, Section 10 of the EOC: Making Complaints

To submit a grievance verbally, contact Customer Service at:
918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a formal grievance in writing, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

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Part C Coverage Decision Requests about Medical Care

Located in Chapter 9, Section 5 of the EOC: Your Medical Care: How to ask for a Coverage Decision or make an Appeal.

To request a coverage decision verbally, contact Customer Service at 1-800-642-8065 or 918-594-5323 (local); TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a request in writing, send to:
CommunityCare Senior Health Plan
Attn: Customer Service
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-594-5250

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)
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Coverage Decision Requests about Part D Prescription Drugs

Located in Chapter 9, Section 6 of the EOC: "How to ask for a coverage decision or make an appeal"

To request a coverage determination verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2311, TTY/TDD: 711, 24 hours a day, seven days a week

To submit a request in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

A letter or the standardized Medicare Prescription Drug Coverage Determination Form may be used to submit a request. Click on the link to print this form.

Enrollees: Providers:
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Making an Appeal about Part C Medical Care

Located in Chapter 9, Section 5 of the EOC: How to ask for a Coverage Decision or make an Appeal.

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. A standardized appeal request form is available. However, you may submit your request in any format. To print this form, click on the following link:

To submit an appeal request in writing, send to:

CommunityCare Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327

Requests for appeals must be in writing unless the request is for a fast or expedited decision. Members must file their appeal request within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Customer Service at 1-800-642-8065 or 918-594-5323 (local); TTY/TDD: 1-800-722-0353. Monday - Friday 8:00 am to 8:00 pm central time.

Fax Number: 918-879-4048

In Person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the unfavorable decision. When we complete the appeal review, we will give you our decision in writing.

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Redetermination (Appeal) for Part D Prescription Drugs

Located in Chapter 9, Section 6 of the EOC: How to ask for a coverage decision or make an appeal



Requests for Appeal Level 1 redeterminations must be in writing unless the request is for a fast or expedited decision.

Members must file their appeal within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Customer Service at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a standard appeal in writing, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)

A standardized Redetermination Request Form is available. However, you may submit your request in any format.

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Prior Authorization or other Utilization Management Requirements for Part D Prescription Drugs

Located in Chapter 5, Section 5 of the EOC: There are restrictions on coverage of some drugs

For prescribing physicians to submit a prior authorization request verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2311, TTY/TDD: 711, 24 hours a day, 7 days a week

To submit a prior authorization in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Number: 1-855-633-7673

Physicians may use the attached Prescription Authorization Form to request prior authorization. Click on the link to print a copy of this form to take to your physician.

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Prescribing Physician's Supporting Statement for Part D Prescription Drugs

Chapter 9, Section 6 of the EOC: How to ask for a coverage decision or make an appeal

There is no standardized form for a prescribing physician to use to present supporting statements or documents.

For a prescribing physician to submit a supporting statement verbally, contact CVS Caremark Part D Exceptions Department at 1-844-232-2311, TTY/TDD: 711, 24 hours a day, seven days a week

To submit supporting documents in writing, send to:
CVS Caremark Part D Exceptions Department
P.O. Box 52000 MC 109
Phoenix, AZ 85072-2000

Fax Numbers: 1-855-633-7673

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Questions about Grievances, Coverage Decisions and Appeals Questions about grievances, coverage decisions and appeals can be answered by our Customer Service Department.

Contact Customer Service at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time
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Contact numbers for Grievances, Coverage Decisions and Appeals For Coverage Decisions about Part D Prescription Drugs: contact CVS Caremark Part D Exceptions Department at 1-844-232-2311, TTY/TDD: 711, 24 hours a day, seven days a week

For Coverage Decisions about Medical Care: contact Customer Service at 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

For Part D or Part C Appeal status: contact Customer Service at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

For Part D or Part C Grievance status: contact Customer Service at 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time
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Appointment of Representative Located in Chapter 9, Section 4 of the EOC: A guide to the basics of coverage decisions and appeals

If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. A completed standardized form is required in order to appoint a representative. To print this form, click on the following link:
This form is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.

Instructions for completing the Appointment of Representative form:
Section 1: The member (beneficiary) completes the requested information in Section I including the name of the individual they appoint as their representative. The beneficiary's signature is required.
Section 2: This section is completed by the individual the beneficiary has named as their representative. The representative's signature is required.
Section 3 and Section 4: These sections may not apply. See page 2 of the form for further information.


To submit a completed Appointment of Representation Form, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: 4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)
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Obtaining an aggregate number of Part C grievances and appeals For information on how to obtain an aggregate number of grievances and appeals, contact Customer Service at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time
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Additional References in Chapter 7 of the EOC For additional detail on coverage decision and appeals, the following sections in Chapter 7 are located in your 2019 Evidence of Coverage :
  • Section 4 - A guide to the basics of coverage decisions and appeals.
  • Section 5 - Your medical care: How to ask for a coverage decision or make an appeal.
  • Section 6 - How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon.
  • Section 7 - How to ask us to keep covering certain medical services if you think your coverage is ending too soon.
  • Section 8 - Taking your appeal to Level 3 and beyond.
  • Section 9 - How to make a complaint about quality of care, waiting times, customer service, or other concerns.
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Disclaimers

  • CommunityCare is an HMO with a Medicare contract. Enrollment in Senior Health Plan depends on contract renewal.
  • You may join or leave a plan only at certain times. Please call Senior Health Plan or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
  • You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
  • Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
  • You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.