Appeals and grievances
Medical and Pharmacy Appeals
An appeal is a request for Commonwealth Care Alliance® (CCA) to review a decision again. This may include decisions about medical care, services, supplies, or prescription drugs. Appeals must be filed within 65 calendar days of the date on your denial notice. CCA may accept an appeal after 65 days if there is good cause for an extension.
You, your primary care provider (PCP), or your appointed representative may file an appeal if coverage for medical care, services, or supplies was denied.
- 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 showing an urgent need.
There are three ways to file a medical appeal:
- Online through the member portal
- Call: 1-866-610-2273 (TTY: 711)
- Mail or fax your written appeal to:
Commonwealth Care Alliance
Attn: Member Appeals
P.O. BOX 1947
Dayton, OH 45401-1947
Fax: 857-453-4517
You will receive an Appeal Acknowledgement Letter after your appeal is received. The letter explains the next steps and the timeframe for a decision.
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 want someone to appeal on your behalf, the request must be signed and mailed or faxed to:
Executive Office of Health and Human Services
Board of Hearings
100 Hancock Street, 6th Floor
Quincy, MA 02171
Fax: 617-847-1204
Keep a copy of your MassHealth (Medicaid) fair hearing request for your records.
If you disagree with a Medicare or MassHealth (Medicaid) Level 2 decision, you may have additional appeal rights under Medicare and MassHealth (Medicaid).
You, your PCP, or your appointed representative may file an appeal if coverage for a prescription drug was denied.
- Standard Pre-service Appeal: Answered within 7 days
- Standard Post-service Appeal: Answered within 14 days
- Expedited Appeal: Answered within 72 hours. Requires a statement from your doctor showing an urgent need
There are two ways to file a pharmacy appeal:
- Call: 1-866-610-2273 (TTY: 711)
- Mail or fax a Request for Redetermination Form to:
Commonwealth Care Alliance
Attn: Member Appeals
P.O. BOX 1947
Dayton, OH 45401-1947
Fax: 857-453-4517
You will receive an Appeal Acknowledgement Letter after your appeal is received. The letter explains the next steps and the timeframe for a decision.
If you disagree with CCA’s Level 1 appeal decision, you may request a Level 2 review by the Medicare IRE. This process is called C2C.
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) 1-833-919-0198
C2C Fax Numbers:
Expedited Appeals: 833-710-0579
Standard Appeals: 833-710-0580
Grievances
A grievance is a complaint about your experience with CCA, a PCP, or a vendor. It does not include coverage or payment decisions. Those are usually handled through the appeal process.
You can file a grievance about:
- The quality of your care
- Wait times
- Customer service
- Delays in responding to a coverage determination, organization determination, or appeal
You or your appointed representative may file a grievance in five ways:
- Online through the member portal
- Call: 1-866-610-2273 (TTY 711)
- Mail or fax your grievance to:
Commonwealth Care Alliance
Attn: Member Appeals
P.O. BOX 1947
Dayton, OH 45401-1947
Fax: 857-453-4517
- Submit your grievance to Medicare
Submit your complaint directly to Medicare with their online form1. Or by calling 800-MEDICARE (1-800-633-4227 or TTY: 877-486-2048), 24/7.
- Submit your grievance to MassHealth
MassHealth Customer Service Center
1-800-841-2900 (TTY: 800-497-4648)
Monday through Friday, 8 a.m. to 5 p.m.
Grievances filed with CCA will be acknowledged in writing. Most grievances are resolved within 30 days.
If you disagree with the grievance decision, call Member Services. Ask for a second review. A different person will complete the second review.
Depending on your plan, your grievance may be resolved by phone or in writing. We will always send a letter if you request one after a verbal resolution.
Any grievance related to quality of care will automatically receive a written response.
How to Get an Aggregate Number of Appeals
You may request the number of appeals and complaints received by CCA One Care in the previous calendar year. Please call Member Services.
Appointing a Representative
You can choose a relative, friend, advocate, PCP, or another person to act as your appointed representative.
If you want someone to act for you, both of you must sign and date a statement giving that person permission to act on your behalf.
An Appointment of Representative form is valid for one year from the date it is signed.
If you are making a request through an appointed representative, complete form CMS-1696 (pdf)1. Then, mail or fax it to:
Commonwealth Care Alliance
Member Services
P.O. BOX 8738
Dayton, OH 45401-8738
Fax: 855-341-0720
The Americans with Disabilities Act (ADA)
The Americans with Disabilities Act (ADA) is a federal law that protects people with disabilities from discrimination.
CCA follows federal civil rights laws and does not discriminate because of a disability.
CCA works to make its services accessible to people with disabilities.
If you need help accessing our services, call 1-866-610-2273 (TTY: 711).
If you have concerns about access to providers, services, or tools, or if you need to file a grievance, call 1-866-610-2273 (TTY: 711).
Appeals and Grievances reviews complaints about accessibility barriers in CCA programs, services, and activities.
You may also contact the CCA ADA Compliance Officer:
Attn: Civil Rights Coordinator
P.O. BOX 1947
Dayton, Ohio 45401
Email: [email protected]
Phone: 1-844-539-1732
Fax: 1-844-417-6254
If you have any questions about appointing a representative, call 1-866-610-2273 (TTY: 711).
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