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Part C Information for Members and ProvidersCoverage Decisions, Appeals (Reconsiderations) and Grievances Coverage Decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. You can ask our plan to make a coverage decision on the medical care you or your doctor is requesting. There are two kinds of coverage decisions, standard or fast. A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more days if you ask for more time, or if we need information (such as medical records) that may benefit you. If your health requires a quick response, you should ask us to make a “fast decision.” A fast decision means we will answer within 72 hours. However, we can take up to 14 more days if we find that some information is missing that may benefit you, or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing. If you ask for a fast decision on your own, without your doctor’s support, our plan will decide whether your health requires that we give you a fast decision. You or your physician can call our Medical Management Department at 1-800-695-1035. TTY users can contact the plan at 1-800-650-2774. If we say yes to your request, we will authorize or provide the care within 72 hours for a fast decision or within 14 days for a standard decision. If we say no to part or all of your request, we will send you a denial in writing that will explain your right to appeal the denial. Information on the aggregate number of CCM Direct’s grievances, appeals, and exceptions is available by contacting CCM Direct Member Services at 1-877-226-8500 (TTY users call: 800-650-2774) Monday - Sunday, 8:00 a.m. – 8:00 p.m. Please review the Evidence of Coverage for more detailed information on coverage decisions and appeals requests. Appeals (Reconsiderations) A member appeal can be submitted when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a services. An appeal must be filed within 60 calendar days of the coverage decision Two types of appeals are available to members - a fast-track appeal and a standard appeal. Members who submit a fast appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours. Standard appeal requests will be reviewed within 30 calendar days. Members can make a fast appeal request by calling 1-877-226-8500 (TTY users should call 1-800-650-2774). If the denial is reversed we will authorize or provide care within 72 hours for a fast appeal or within 30 days for an standard appeal. If our answer is no to part or all of what you requested, we will send you a written denial notice informing you that we have sent your appeal to the Independent Review Organization for a Level 2 Appeal. Grievances A grievance is any complaint other than one that involves a coverage decision. You would file a grievance if you have any type of problem with CCM Direct or one of our network providers that does not relate to coverage for a service. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to: Comprehensive Care Management You can also fax a grievance to: 1-718-944-2149. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-877-226-8500 (TTY users call: 1-800-650-2774) Monday - Sunday, 8:00 a.m. to 8 p.m.
Part D Information for Members and ProvidersCoverage Determinations/ Exception Requests, and Appeals and Grievances Coverage Determinations/Exception Requests For situations in which you have a medication that is not on CCM Direct’s formulary or is part of a tier level designated as non-preferred, but you believe it should be placed in a different tier, an exceptions process has been established by the plan. Exception requests will be reviewed by the Plan for coverage determination. Your prescribing physician must provide supporting medical information in response to a coverage exception request related to a non-formulary drug or tier placement. There are two kinds of coverage determination requests - fast and standard. A member can request a fast coverage determination, which will be decided within 24 hours. The request for a fast coverage determination must meet criteria that the standard coverage determination review process time frame would jeopardize the member’s health status. For standard coverage determination requests, notification will occur 72 hours after receipt of the request or written documentation of medical necessity from the physician. Non-formulary drugs approved for coverage will be covered at the non-preferred brand level. Biotech and specialty non-formulary products approved for coverage will be covered at the specialty level. A fast coverage determination or exception request can be made verbally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. – 8:00 p.m. To make a coverage determination request or an exception request, see instructions and forms below.
Coverage Determination Form (for submission by Members) Information on the aggregate number of CCM Direct’s grievances, appeals, and exceptions is available by contacting CCM Direct Member Services at 1-877-266-8500 (TTY users call: 1-800-650-2774) Monday - Sunday, 8:00 a.m. – 8:00 p.m. Please review the Evidence of Coverage for more detailed information on coverage determination, exception requests and appeals requests. Appeals (Redetermination and Reconsideration) A member appeal can be submitted when you want us to reconsider and change a decision we have made about what prescription drug benefits are covered for you or what we will pay for a prescription drug. An appeal must be filed within 60 calendar days of the coverage determination. Two types of appeals are available to members - a fast-track appeal and a standard appeal. Members who submit a fast appeal must meet criteria that the standard process time frame would jeopardize the member's health status. These fast reviews will be completed within 72 hours. Standard appeal requests will be reviewed within 7 calendar days. Members can make a fast appeal request by calling 1-877-226-8500 (TTY users should call 1-800-650-2774). To make a standard appeal request, see instructions and attached forms below.
Member IRE Reconsideration Form (Last Updated: January 1, 2009) How to Appoint 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 ask for a coverage decision or make an appeal. There may be someone who is already legally authorized to act as your representative under State law. If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the form to give that person permission to act on your behalf. You can also get the form from the link below. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form. Member IRE Reconsideration Form (Last Updated: January 1, 2009) Grievances A grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with CCM Direct or one of our network pharmacies that does not relate to coverage for a prescription drug. If you have a grievance, we encourage you to call Member Services for a prompt response. We will try to resolve any complaint over the phone. You may also send your complaint in writing. To submit a grievance in writing, please mail to:
Medco Health Solutions, Inc. You can also fax a grievance to: 1-972-915-6104. We will notify you of a decision within 30 days of receipt of the written grievance. We may extend this time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. An expedited grievance can be made orally by calling 1-800-935-7195 (TTY/TDD users call: 1-800-855-2881) Monday - Sunday, 8:00 a.m. to 8 p.m. Member Rights and Responsibilities As a Medicare beneficiary, you have certain rights that protect you. These rights include:
If you elect to disenroll from CCM Direct, you also have rights and responsibilities. These include:
CCM Direct can disenroll a beneficiary in the following circumstances:
Together with your rights as a CCM Direct member, you also have the responsibility to:
Please access the Evidence of Coverage for more detailed information on all Member Rights and Responsibilities including disenrollment situations and procedures. Prior Authorization Criteria You will need authorization before filling prescriptions for the drugs shown in the chart here: "2009 Prior Authorization Criteria". We will only provide coverage after it determines that the drug is being prescribed according to the criteria specified in the chart. You, your pharmacist, or your physician can request prior authorization by calling Medco toll-free at 1-800-753-2851, 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday. Customer Service is available in English and other languages. TTY/TDD users should call 1-800-716-3231. Transition Policy New members in our plan may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 of your Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we provide you with the opportunity to request a formulary exception in advance for the following year. When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 31-day supply (unless the prescription is written for fewer days). After we cover the temporary 31-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the 90 days a new member is enrolled in our Plan. If the resident has been enrolled in our Plan for more than 90 days and needs a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access. See Section 10 of your Evidence of Coverage for information about non-Part D drugs. Best Available Evidence of Low-Income Subsidy Status If you believe that you are paying too much for your prescription drugs because CCM does not have the correct low-income subsidy status, please call our Member Services Department. We can help you find out if you should be paying less for your prescription drugs because you are eligible for Medicaid and/or the low-income subsidy. Please visit the following website for more information: http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp. |
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We welcome your inquiries. Please call our Member Services Department at 1-877-226-8500 7 days a week from 8:00 AM through 8:00 PM. TTY users should call 1-800-650-2774. You can also email us at CCM-MemberServices@bethabe.org or write to us at: Comprehensive Care Management Comprehensive Care Management (CCM) is a member of the Beth Abraham Family of Health Services. CCM is a Health Maintenance Organization with a Medicare Advantage Contract. H5989_WEB_2009_003v2 05/2010 This page was last modified on June 7, 2010. |