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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 (Payment) 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: 833-346-9222 (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: Depending on if the service under appeal is covered by Medicare, Medicaid, or both, there are different Level 2 appeal routes. For services covered by Medicare and Medicaid, both Level 2 processes may be conducted at the same time. The decision most favorable to the member applies when there are two Level 2 decisions.

Medicare covered services are automatically forwarded to the Level 2 Independent Review Entity (IRE) for review. For services covered by Medicaid, you may request a Level 2 appeal with the RI State Fair Hearing office, which is facilitated by the Executive Office of Health and Human Services (EOHHS), 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.

To request a State Fair Hearing, you can either:

  • Call 401-462-2132 (TDD 401-462-3363) after you have finished the internal appeal process, or
  • Fax your request to 401-462-0458, or
  • Email your request to [email protected], or
  • Mail your request to:

EOHHS Appeals Office
Virks Building
3 West Road
Cranston, RI 02920

Please keep one copy of your RI fair hearing request for your records. If the Level 2 decision is unfavorable, there are additional levels of Medicare and Medicaid Appeal as described in the Level 2 denial notice, including a Medicare Administrative Law Judge (ALJ) hearing, a Medicare Appeal Counsel (MAC) review or Federal and State Court.

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-Service (Payment) Appeal: Answered in 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 fax a Request 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 or your representative may request a Level 2 review by the Medicare IRE, called C2C Innovative Solutions, 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: 833-346-9222 (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 the RI Office of the Health Insurance Commissioner (OHIC)

RI Insurance Resource, Education, and Assistance Consumer Helpline (RIREACH)
300 Jefferson Blvd, Suite 300, Warwick, RI 02888
Telephone: 855-747-3224 (TTY 711)

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 833-346-9222 (TTY 711).

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