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Medical and Pharmacy Appeals

An appeal is a request from you or your doctor when you’d like Commonwealth Care Alliance (CCA) to re-evaluate a decision we made about what medical care, services, supplies, or prescriptions are covered.

Appeals need to be filed within 60 calendar days of the date on the denial notice you receive for a coverage determination or organization determination. CCA can accept an appeal beyond 60 days if good cause for an extension is shown.

You, your doctor, or an appointed representative have the right to file an appeal if we denied coverage for medical care, services, or supplies.

  • Standard Pre-Service Appeal: Answered within 30 days
  • Standard Post-Service Appeal: Answered within 60 days
  • Expedited Appeal: Answered within 72 hours. Requires a statement from your doctor indicating an urgent need.

There are two ways you, your doctor, or your appointed representative may file a medical appeal:

  1. Call us at: 866-610-2273 (TTY 711)
  2. Mail or fax your written appeal to:
    Commonwealth Care Alliance
    Appeals and Grievances Department
    30 Winter Street
    Boston, MA 02108
    Fax: 857-453-4517

Members will receive an Appeal Acknowledgement Letter once the appeal has been initiated. This letter will document the next steps of the appeal process as well as the timeframe within which CCA must respond to the appeal based on the request type (standard vs. expedited).

Timeline of Appeals:

  • Level 1 Appeal: Denied by CCA
  • Level 2 Appeal: Automatically filed with the Medicare Independent Review Entity (IRE) for any Medicare covered services. Members must file for a Level 2 appeal with Masshealth directly for Medicaid covered services. You may request to appeal with MassHealth no later than 120 calendar days from the date you received your written appeal denial notice. You will be sent a form to file a State Fair Hearing Request with your appeal denial. When both Level 2 processes are engaged, the decision most favorable to the member applies.

If you would like to name a representative to appeal on your behalf, the request must be signed and sent by mail or fax to:

Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Fax: 617-847-1204

Please keep one copy of your MassHealth fair hearing request for your records. If you do not agree with the Medicare or MassHealth Level 2 appeal decisions, you have additional appeal rights under Medicare and MassHealth.

You, your doctor, or an appointed representative have the right to file an appeal if we denied coverage for your prescription drugs.

  • Standard Pre-Service Appeal: Answered within 7 days
  • Standard Post-Services Appeal: Answered within 14 days
  • Expedited Appeal: Answered in 72 hours and requires a statement from your doctor indicating an urgent need

There are two ways you, your doctor, or an appointed representative may file a pharmacy appeal:

  1. Call us at: 866-610-2273 (TTY 711)
  2. Mail or faxRequest for Redetermination Form to:

Commonwealth Care Alliance
Appeals and Grievances Department
30 Winter Street
Boston, MA 02108
Fax: 857-453-4517

Members will receive an Appeal Acknowledgement Letter once the appeal has been initiated. This letter will document the next steps of the appeal process as well as the timeframe within which CCA must respond to the appeal based on the request type (standard vs. expedited).

If you do not agree with the Level 1 appeal decision by CCA, you may request a Level 2 review by the Medicare IRE, called C2C, by calling or writing to the address below:

Part D Prescription Drug Benefit and DMP At-Risk Appeals:

C2C Innovative Solutions, Inc.
Part D Drug Reconsiderations
P.O. Box 44166
Jacksonville, FL, 32231-4166

C2C Customer Service: (Toll free) 833-919-0198

C2C Fax Numbers:
Expedited Appeals: (833)710-0579
Standard Appeals: (833) 710-0580

Grievances

A grievance is a complaint about any aspect of your experience with CCA, its providers, or vendors other than coverage or payment decisions (these issues are usually handled by the appeal process). You might file a grievance if you had any type of problem with the quality of your medical care, waiting times, or the customer service you receive. You could also file a grievance if you do not think we responded quickly enough to your request for coverage determination or organization determination, or to your appeal of that determination.

There are four ways you or your appointed representative may file a grievance:

  1. Call us at: 866-610-2273 (TTY 711)
  2. Mail or fax your grievance to:

Commonwealth Care Alliance
Appeals and Grievances Department
30 Winter Street
Boston, MA 02108
Fax: 857-453-4517

  1. Submit your grievance to Medicare

Submit your complaint directly to Medicare by using their online form1 or by calling 800-MEDICARE (800-633-4227 or TTY 877-486-2048), 24 hours a day, 7 days a week.

  1. Submit your grievance to MassHealth

MassHealth Customer Service Center
800-841-2900 (TTY 800-497-4648)
Monday to Friday, 8 am to 5 pm

Grievances filed with the CCA will be acknowledged in writing and most resolved within 30 days. If you disagree with the results of a grievance resolution, you can appeal this resolution by calling Member Services and asking for a second review of your grievance. The second review will be conducted by a different person than the first. 

Depending on you plan type, your grievance may be resolved orally or in writing. We will always send a letter if you ask for it after a verbal resolution. Any grievance related to the quality of care you received will automatically be responded to in writing.

Appointing a Representative

If you need someone to file a grievance or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. A CMS representative form is valid for one year from the date both parties sign the document.

If you are making a request through an appointed representative, you should download form CMS-1696 (pdf),1 complete it, and mail or fax it to:

Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108
Fax: 855-341-0720

If you have any questions about naming your appointed representative, you can call us at 866-610-2273 (TTY 711).

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