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Medical and Pharmacy Appeals

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.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the coverage decision we made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. Under certain circumstances, which we discuss later, you can request an expedited or “fast coverage decision” or a fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

How to Make a Level 1 Appeal for Medical Care

For more information on the medical care appeal process, you may refer to Chapter 9, Section 5 of the Evidence of Coverage (EOC).

If your health requires a quick response, you must ask for a “fast appeal.”

  • To start an appeal you, your doctor, or your representative, must contact us.
  • If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. You may also ask for an appeal by calling us.
  • If you are asking for a fast appeal, make your appeal in writing or call us.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
  • You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
    • You have the right to ask us for a copy of the information regarding your appeal.
    • If you wish, you and your doctor may give us additional information to support your appeal.

CALL: 1-866-333-3530
Calls to this number are free. Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY: 711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax: 1-866-207-6539

Write:

CCA Health California
Member Services Department (Appeals)
18000 Studebaker, Road, Suite 150
Cerritos, CA 90703

Click here to download the Appeal form (Reconsideration Request form for Medical Care):

Appeals Form for Medical Care (English)

Appeals Form for Medical Care (Spanish)

Appeals Form for Medical Care (Chinese)

Appeals Form for Medical Care (Korean)

Appeals Form for Medical Care (Vietnamese)

Download Adobe Acrobat Reader1

For expedited requests, please call or fax using the contact numbers above.

If your health requires it, ask for a “fast appeal” (you can make a request by calling us)

  • If you are appealing a decision we made about coverage for care you have not yet received, you and/or your doctor will need to decide if you need a fast appeal.
  • The requirements and procedures for getting a fast appeal are the same as those for getting a fast coverage decision. To ask for a fast appeal, follow the instructions for asking for a fast coverage decision. (These instructions are given earlier in this section.)
  • If your doctor tells us that your health requires a fast appeal, we will give you a fast appeal.

When our plan is reviewing your appeal, we take another careful look at all of the information about your request for coverage of medical care. We check to see if we were following all the rules when we said no to your request.

We will gather more information if we need it. We may contact you or your doctor to get more information.

Deadlines for a “fast appeal”

  • When we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to do so.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.

Deadlines for a “standard appeal”

  • If we are using the standard deadlines, we must give you our answer within 30 calendar days after we receive your appeal if your appeal is about coverage for services you have not yet received. We will give you our decision sooner if your health condition requires us to.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 30 calendar days after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization for a Level 2 Appeal.

To make sure we were following all the rules when we said no to your appeal, we are required to send your appeal to the Independent Review Organization. When we do this, it means that your appeal is going on to the next level of the appeals process, which is Level 2.

How to Make a Level 2 Appeal for Medical Care

If we say no to your Level 1 Appeal, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews our decision for your first appeal. This organization decides whether the decision we made should be changed.

  • The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work.
  • We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.
  • You have a right to give the Independent Review Organization additional information to support your appeal.
  • Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal.

The Independent Review Organization will tell you its decision in writing and explain the reasons for it.

  • If the review organization says yes to part or all of what you requested, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization for standard requests or within 72 hours from the date the plan receives the decision from the review organization for expedited requests.
  • If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision” or “turning down your appeal.”)
  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. The details on how to do this are in the written notice you got after your Level 2 Appeal.
  • The Level 3 Appeal is handled by an Administrative Law judge or attorney adjudicator. Section 9 in Chapter 9 tells more about Levels 3, 4, and 5 of the appeals process.

How to Make a Level 1 Appeal for Drugs

For more information on the drug coverage appeal process, you may refer to Chapter 9, Section 6 of the Evidence of Coverage (EOC).

If your health requires a quick response, you must ask for a “fast appeal.”

  • To start your appeal, you (or your representative or your doctor or other prescriber) must contact us.
  • If you are asking for a standard appeal, make your appeal by submitting a written request. You may also ask for an appeal by calling us.
  • If you are asking for a fast appeal, you may make your appeal in writing or you may call us.
  • We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website.
  • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision.
  • You can ask for a copy of the information in your appeal and add more information.
    • You have the right to ask us for a copy of the information regarding your appeal.
    • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.

Call: 1-888-254-9907
Calls to this number are free. Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY: 711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax: 1-858-790-6060

Write:

MedImpact HealthCare Services
Attn: Appeals Coordinator
10181 Scripps Gateway Ct.
San Diego, CA 92131

Click here to download the Appeal Form (Redetermination Request form) for Drugs:

Appeal Form for Drugs (English)

Appeal Form for Drugs (Spanish)

Download Adobe Acrobat Reader1

For expedited requests, please call or fax using the contact numbers above.

 

If your health requires it, ask for a “fast appeal”

  • If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal.
  • The requirements for getting a fast appeal are the same as those for getting a “fast coverage decision” in Section 6.4 of Chapter 9.

When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a “fast appeal”

  • If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.
  • If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.

Deadlines for a “standard appeal”

  • If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal for a drug you have not received yet. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for fast appeal.
  • If our answer is yes to part or all of what you requested:
    • If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal.
    • If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision.
  • If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request.
  • If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal.

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal.

If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below).

How to Make a Level 2 Appeal for Drugs

If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed.

  • If we say no to your Level 1 Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization.
  • When you make an appeal to the Independent Review Organization, we will send the information we have about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file.
  • You have a right to give the Independent Review Organization additional information to support your appeal.

The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us.

Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called “upholding the decision” or “turning down your appeal.”)

If the Independent Review Organization “upholds the decision,” you have the right to a Level 3 Appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get from the Independent Review Organization will tell you the dollar value that must be in dispute to continue with the appeals process.

  • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).
  • If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal.
  • The Level 3 Appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in Chapter 9 tells more about Levels 3, 4, and 5 of the appeals process.

Grievances

The formal name for “making a complaint” is “filing a grievance.” The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.

You can make a complaint about us or one of our network providers or pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes.

There are two types of processes for handling problems and concerns:

  1. For some types of problems, you need to use the process for coverage decisions and appeals.
  2. For other types of problems, you need to use the process for making complaints.

The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.

  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can contact Member Services at 1-866-333-3530. TTY users can call 711. Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays.
  • If you do not wish to call, you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
  • Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
  • If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint.” If you have a “fast complaint,” we will give you an answer within 24 hours.

Mailing Address:
CCA Health of California
Member Services Department (Complaints)
18000 Studebaker Road, Suite 150
Cerritos, CA 90703

Fax Number: 1-866-207-6539

 

Click below to download the Grievance form (Complaint):

Grievance form (Complaint): English

Grievance form (Complaint): Spanish

Grievance form (Complaint): Chinese

Grievance form (Complaint): Korean

Grievance form (Complaint): Vietnamese

 

  • If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
  • To have a complaint reviewed, you should contact us promptly by phone or in writing. We must address your complaint as quickly as your case requires based on your health status, but no later than 30 days after we receive your complaint. We may extend the time frame by up to 14 calendar days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

You can submit a complaint about CCA Health directly to Medicare. To submit an online complaint to Medicare, go to https://www.medicare.gov/MedicareComplaintForm/home.aspx.1

For more information on the drug coverage appeal process, you may refer to Chapter 9, Section 10 of the Evidence of Coverage (EOC), which you can find at the bottom of the Member Benefits page.


Appointing a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Mailing Address:
CCA Health California
Member Services Department
18000 Studebaker Road, Suite 150
Cerritos, CA 90703
Fax Number: 1-866-207-6539


You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Member Services at 866-333-3530 (TTY: 711). Hours are 8 am to 8 pm, seven days a week, from October 1 through March 31, except holidays, and 8 am to 8 pm, Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

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