Appeals and Grievances

As our member, you have the right to file a complaint (either an appeal or a grievance) if you have concerns or problems related to your coverage.

Becoming an Appointed Representative

Our members can appoint a caregiver to act on their behalf. To do so, we must have written authorization signed by both the caregiver and the member.

A representative who is appointed by the court or who is acting in accordance with state law may also file a request on your behalf after sending us the legal representative document. You will not need to complete an Appointment of Representative Form if you provide another legal representation document with your request.

Download an Appointment of Representative form (PDF). Once the form is filled out in its entirety fax it to the Customer Service at 1-866-684-5378.

What is an appeal?

A complaint you file to ask us to reconsider and change a decision we have made about what prescription medicine benefits are covered, or what we will pay for a particular medicine. You can find more information about what your plan covers in your Evidence of Coverage.

When should I consider filing an appeal?

You can appeal if Medicare or Community CCRx^SM denies one of the following:

• A request for a healthcare  supply, or prescription that you believe you should be able to receive
• A request for payment for a prescription drug you already received
• A request to change the amount you must pay for a prescription drug

How do I file an appeal with Community CCRx?

You must file your appeal within 60-days of the date on the letter that is attached to the coverage determination notification. If you happen to miss the 60-day deadline, we may grant you an extension on a case-by-case basis. A coverage determination is the first decision made by Community CCRx (not the pharmacy) about your drug coverage, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.

To file a standard appeal, you can send the appeal request to us in writing at:

• Appeals and Coverage Determination
  PO Box 391197
  Solon, OH 44139-3911

You may also file an appeal by phone. To file an appeal, or if you or your physician has any general questions about the appeals or process, call us at 1-866-316-6049 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-777-9083) every day.

If we deny all or part of your appeal request, you or your appointed representative may request a review by an independent review entity (IRE). The IRE is contracted directly with the federal government and is not affiliated with Community CCRx in any way. You can access a reconsideration form (PDF) here.

Reconsideration Notice

If you don't agree with the redetermination decision, you should use this Reconsideration Form (PDF) to appeal your claim. This is called a reconsideration and is the second level of the appeals process. Any dollar amount can be appealed at this level, but it needs to be submitted within 60 days from the date you received the redetermination decision.

To file a Reconsideration Form, you can send or fax the form to us in writing at:

• MAXIMUS Federal Services
  Medicare Part D QIC
  860 Cross Keys Office Park
  Fairport, NY 14450
• Fax: 1-585-425-5301
• Toll Free Fax: 1-866-825-9507

You may also file a Reconsideration Form by phone or fax.  If you have any general questions about the Reconsideration Form, call us at 1-866-316-6049 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-777-9083) every day.

Please refer to your Evidence of Coverage, section on Appeals, for more information on what to do next.

What is a Grievance?

A complaint you file for any other type of problem with Community CCRx or one of our network pharmacies.

When should I consider filing a grievance?

• If you have a problem with waiting times when filling a prescription at a network pharmacy
• If you believe the behavior at a network pharmacy is inappropriate
• If you are having difficulty reaching someone by phone or getting information you requested
• If you have a problem with the cleanliness or conditions of a network pharmacy
• If you experience a problem with Community CCRx customer service
• If you don’t understand or are confused by written materials provided by Community CCRx

How do I file a grievance with Community CCRx?

If you have a grievance or a question about grievances, we encourage you to first call Customer Service at 1-866-684-5353 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) every day. We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Community CCRx Grievance Process.

You may file a grievance by telephone, fax, or through the mail, no later than 60 days after the event that caused the grievance. When you file a written grievance you will receive a written confirmation that your grievance was received. All written grievances will be responded to in writing no later than 30 days from the date that the grievance was received by Community CCRx.

If your grievance involves a refusal by Community CCRx to grant your request for an expedited coverage determination or an expedited redetermination, and you have not yet received the medication that is in dispute, you may file an expedited (fast) grievance. To file an expedited grievance, please contact the Customer Service at 1-866-684-5353 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-866-684-5351) every day, or fax your written complaint to 1-866-868-0858. In this case, you will receive a response within 24 hours.

You can file a grievance by mail at:

• Medicare Prescription Drug Program
  P.O. Box 5203
  Rennselaer, NY 12144-5203
• Fax: 1-866-684-5378

Please do not file an expedited grievance by mail, as we cannot guarantee a response within 24 hours.

In certain circumstances, Community CCRx may extend the 30-day response time by 14 days. We may also extend the timeframe if you request us to do so. Community CCRx may also extend the timeframe if we are in need of additional information. In this case, we only extend the timeframe if the delay is in your best interest and you will receive a letter notifying you of the extension.

Please refer to your Evidence of Coverage, section on Grievances, for more information on what to do next.