Grievance and Appeal Process for CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan)

Because you have Medicare and Medi-Cal (Medicaid), you have different processes that you can use to handle your grievances or appeals. Which process you use depends on whether the problem is about Medicare benefits or Medi-Cal (Medicaid) benefits. If your problem is about a benefit covered by Medicare, then you should use the Medicare process. If your problem is about a benefit covered by Medi-Cal (Medicaid), then you should use the Medi-Cal (Medicaid) process. If you would like help deciding whether to use the Medicare process or the Medi-Cal (Medicaid) process, please contact our Customer Service Department at 1-888-244-4430.

 

How to File a Part C Appeal or Grievance?

Part C (Medicare) Grievance and Appeals Process

As a member of CommuniCare Advantage Cal MediConnect, we encourage you to please let us know if you have concerns or problems related to your coverage or the care you receive. CommuniCare Advantage Cal MediConnect Customer Service staff is always ready to help you solve any problems you have about your care. Our Customer Service Staff will try to resolve any complaint that you might have over the phone. 

 

What is a Grievance

A grievance is a type of complaint you make if you are dissatisfied with CommuniCare Advantage Cal MediConnect or our contracted providers for reasons other than a coverage decision. Grievances do not involve problems related to approving or paying for Part D drugs. You or your appointed representative may file a grievance within 60 days of the event or incident. You may file a grievance by contacting the CommuniCare Advantage Cal MediConnect Customer Service Department toll free at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage Cal MediConnect Plan representatives are available 24 hours a day, 7 days a week, including holidays. You may opt to submit your Grievance in a letter and send it directly to CommuniCare Advantage Cal MediConnect Plan at the following address:

CommuniCare Advantage Cal MediConnect 

Attention: Grievance & Appeals Manager
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

Or fax to (619) 407-4646

You will receive a written letter telling you that CommuniCare Advantage Cal MediConnect Plan 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 CommuniCare Advantage Cal MediConnect Plan receiving your grievance.

For questions about the status of your grievance, call Customer Service Department at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage Cal MediConnect Plan representatives are available 24 hours a day, 7 days a week, including holidays.

For additional information regarding CommuniCare Advantage Cal MediConnect grievance process, please see the Member Handbook.

 

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);

The completed form should be faxed, mailed, or delivered in person to:

CommuniCare Advantage Cal MediConnect 

Attention: Grievance & Appeals Manager
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

Or fax to (619) 407-4646

 

Grievance Process

There are two kinds of grievances that you can request:

Fast Grievance (24 hour): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with CommuniCare Advantage Cal MediConnect 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. CommuniCare Advantage Cal MediConnect 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. CommuniCare Advantage Cal MediConnect must respond to you as promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint. CommuniCare Advantage Cal MediConnect may extend the timeframe by up to 14 days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.

If you are concerned about the quality of care you received, you can also send your complaint to CommuniCare Advantage Cal MediConnect Plan, 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 
1-855-887-6668 TTY

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.

 

How to File a Medicare Organization Determination (Coverage Decision or Coverage Determination)

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

  • You can call us at: 1-888-244-4430. TTY: 1-855-266-4584.
  • You can fax us at: 619-213-1008.
  • You can to write us at:

CommuniCare Advantage Cal MediConnect Plan 

2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

 

How long does it take to get a coverage decision?

It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal.

 

Asking for a fast coverage decision:

  • If you request a fast coverage decision, start by calling or faxing our plan to ask us to cover the care you want.
  • You can call us at 1-866-244-4430 or fax us at 619-213-1008. For details on how to contact us, go to Chapter 2, Section A, page 14 of the Member Handbook.
  • You can also have your doctor or your representative call us.

 

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 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. We will also use the standard 14 calendar day 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.

 

Appeals

As a member, you can file an appeal if CommuniCare Advantage Cal MediConnect Plan 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 CommuniCare Advantage Cal MediConnect Plan. You, your prescribing physician or other prescriber acting on your behalf and upon providing notice to you, or your appointed representative must file a written request for appeal within sixty (60) calendar days from the date of the notice of the organization / coverage (i.e., the date printed or written on the notice). You must send your appeal in writing to:

CommuniCare Advantage Cal MediConnect 

Attention: Grievance & Appeals Manager
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

Or fax to (619) 407-4646

You will receive a written letter telling you that CommuniCare Advantage Cal MediConnect Plan 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 CommuniCare Advantage Cal MediConnect Plan receiving your grievance.

For additional information regarding CommuniCare Advantage Cal MediConnect grievance process, please see the Member Handbook.

For questions about the status of your appeal, or to obtain an aggregate number of grievances, appeals and exceptions filed with CommuniCare Advantage Cal MediConnect Plan, contact the Customer Service Department at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage Cal MediConnect Plan 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. However, if you request, or if we find that some information is missing which can help you, we can take up to 14 more days to make our decision.

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. CommuniCare Advantage Cal MediConnect will give you a decision no later than 60 days after we get your appeal. If we do not decide within 60 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, CommuniCare Advantage Cal MediConnect will automatically give you a fast appeal.

If you or your appointed representative asks for a fast appeal without support from a doctor, CommuniCare Advantage Cal MediConnect 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.

How do I file an Appeal with CommuniCare Advantage Cal MediConnect Health Plan?

For a fast appeal, you, your doctor, or your appointed representative should contact Customer Service by telephone at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage Cal MediConnect Health Plan representatives are available 24 hours a day, 7 days a week, including holidays.

You, your treating physician, or appointed representative should mail, fax or deliver your written appeal to:

CommuniCare Advantage Cal MediConnect 

Attention: Grievance & Appeals Manager
2420 Fenton Street, Suite 100 
Chula Vista, CA 91914 

Or fax to (619) 407-4646

You should include your name, address, subscriber 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.

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 CommuniCare Advantage Cal MediConnect 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 CommuniCare Advantage Cal MediConnect 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.

 

How to File a Grievance for a Medi-Cal Benefit

A grievance is an expression of dissatisfaction. Grievances include complaints and appeals. Filing a grievance can be as easy as calling Customer Service or asking that we mail you a grievance form. Your primary care site also has grievance forms. Grievances can also be filed ‘online’ through our internet web site, www.chgsd.com, via fax (619) 476-3834, or in person. For us to accept your grievance for resolution, it must be filed with us within 180 days following any incident or action that is the subject of dissatisfaction. If you submit your grievance by telephone and we resolve it by the end of the next business day, we let you know, and you won’t hear anything else from us on the matter. If your problem takes more time to resolve, we send you a letter within five days of receiving your grievance. The letter tells you that we are working on resolving it. Grievances for IHSS hours authorized by counties shall be connected to the San Diego County Aging and Disability Resource Connection (ADRC) toll-free at 1-800-510-2020, consistent with the IHSS grievance and appeals process governed by state law and regulation.

 

Non-urgent vs. Urgent Grievances

If your grievance is non-urgent, you will hear back from us within 30 days of the date we get your grievance. At that time, we tell you the final resolution and provide information about your other rights with respect to the grievance.

Urgent grievances are handled more quickly. An urgent grievance is one that involves an immediate and serious threat to your life or health. An urgent grievance includes, but is not limited to, severe pain or the potential for loss of life, limb or major bodily function. For urgent grievances, you will hear back from us within three days - or sooner if need be. This time may be extended by 14 days if you ask for an extension, or we show that there is a need for further information about your grievance and the delay is in your best interest. When we get a grievance that we determine to be urgent, we immediately inform you about your right to call the California Department of Managed Health Care (DMHC). If you have an urgent grievance, there is no need for you to participate in our grievance process before calling the DMHC for assistance. 

Please keep in mind that our clinical staff is involved in reviewing all grievances that involve quality of care issues.

 

Appeals for Medi-Cal Benefits

We may make decisions with which you are not satisfied. For example, you may be unhappy with our decision to deny, delay or change a health care service, and ask us to reconsider our decision. Or, we have made a decision that adversely affects your relationship with us. In cases like these, you may file an appeal, which is a request to change a decision. 

From the date we, or one of our contracted medical groups or IPAs, notify you of our decision to deny, delay or change a health care service, you have 90 days to appeal. If conditions beyond your control prevent you from filing an appeal within 90 days, you must file an appeal as soon as reasonably possible. If you are unable to file an appeal within 90 days, you must explain to us why you were unable to meet this timeline, and show us that you filed the appeal as soon as was reasonably possible. When you appeal our decision, the same timelines for processing a grievance apply: 

We will reconsider our decision and get back to you within 30 days of receiving your appeal. If we determine the appeal to be urgent, we will get back to you within three calendar days or sooner if your health condition requires it.

 

State Fair Hearing Process

The Department of Social Services administers a Fair Hearing process. You have a right to a State Fair Hearing if services that your doctor asked to have been denied or stopped. If you get a written notice denying health services, that notice will include a form for you to file a grievance with CHG. But it is your right to ask for a State Fair Hearing with or without Filing a grievance with us or waiting for a decision from us about your grievance. 

To be eligible for a State Fair Hearing, you must ask for it within 90 days of receiving our decision to deny or stop services. To ask for a hearing, call the Department of Social Services at 1-800-952-5253, or send a letter asking for the hearing to: 

 

California Department of Social Services 

State Hearings Division 
P.O. Box 944243, MS 19-17-37 
Sacramento, CA 94244-2430 



If you need help with asking for a State Fair Hearing, please call Customer Service at 1-888-244-4430. If you are granted a State Fair Hearing, you may represent yourself or be represented by an authorized third party such as legal counsel, relative, friend or any other person.

Some grievances, due to their urgency, may be eligible for an Expedited State Hearing (ESH). For more information on expedited State Fair Hearing, please refer to the Member Handbook.

 

Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-244-4430 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site https//www.hmopelp.ca.gov has complaint forms, IMR application forms and instructions online. 

You are not required to participate in CHG’s grievance process before seeking an IMR of our decision to deny coverage of an experimental/ investigational therapy. 

An IMR is available in the following situations:

  1. (a) Your doctor has recommended a health care service as medically necessary, or (b) You have gotten urgent care or emergency services that a doctor determined was medically necessary, or (c) You have been seen by an in-plan doctor for the diagnosis or treatment of the health condition for which you seek independent review, without a provider recommendation in (a) above or urgent or emergency services in (b) above. The in-plan provider need not recommend the disputed health care service as a condition for the enrollee to be eligible for an IMR. The provider may be an out-of-plan provider. However, the plan will not have liability for payment of services unless required by the director for services determined from the IMR to be a medically necessary covered benefit or reasonable under the emergency or urgent medical circumstances; and 
  2. The disputed health care service has been denied, modified, or delayed by CHG or one of its plan doctors, based in whole or in part on a decision that the health care service is not medically necessary; and 
  3. You have filed a grievance with CHG and the disputed decision was upheld or the grievance remains unresolved after 30 calendar days. If your grievance is eligible for expedited review, you are not required to file a grievance with CHG before asking for an IMR. If there is an imminent and serious threat to the health of the enrollee, all necessary information and documents shall be delivered to an independent medical review organization within 24 hours of approval of the request for review. Also, the DMHC may waive the requirement that you follow CHG’s grievance process in extraordinary and compelling cases. For cases that are not urgent, the IMR organization designated by DMHC will provide its determination within thirty (30) days of receipt of your application and supporting documents. For urgent cases involving an imminent and serious threat to your health, but not limited to severe pain, potential loss of life, limb or major bodily function; the IMR organization will provide its determination within three (3) days of the receipt of the information. At the request of the experts, the deadline can be extended by up to three (3) days if there is a delay in getting all needed documents. The IMR process is in addition to any other procedures or remedies that may be available to you. A decision not to participate in the IMR process may cause you to forfeit any statutory right to pursue legal action against the plan about the care that was requested. You pay no application or processing fees for an IMR. You have the right to provide information in support of your request. For more information about the IMR process or to ask for an application form, please call CHG’s Customer Service at 1-888-244-4430. The hearing impaired may call Customer Service through the California Relay Service at (1-(800) 735-2929).

 

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  http://www.medicare.gov

 

Disclaimers

CommuniCare Advantage Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Enrollment in CommuniCare Advantage Cal MediConnect Plan depends on contract renewal.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook.

Limitations, copays and restrictions may apply. For more information, call CommuniCare Advantage Cal MediConnect Customer Service or read the CommuniCare Advantage Cal MediConnect Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change on January 1 of each year.

Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

English

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Español (Spanish)

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tagalog (Tagalog - Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

العربیة (Arabic)

ملحوظة: اذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة  اللغوية تتوافر لك بالمجان. اتصل برقم

Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584)


   

Last update 01/18/2018

H5172_Website2017 Approved 1/17/17