Medicare Part C and Part D Grievances, Coverage Decisions and Appeals Summary

The resource information linked to the CommunityCare Senior Health Plan formulary web page pertaining to grievances, coverage decisions (including exceptions), and appeals processes are taken directly from the 2017 Evidence of Coverage (EOC) document Members receive at the beginning of each year. To print a copy of the current plan year Evidence of Coverage (EOC) for Platinum, Platinum Plus or Silver Plus, please click the link.

Click on a topic below for more information.

Instructions for Filing a Grievance about Medical Care or Part D Prescription Drugs
Coverage Decision Requests - Part C
Coverage Decision Requests - Part D
Reconsideration (Appeals) – Part C
Redetermination (Appeal) - Part D
Part D Prior Authorization or other Utilization Management Requirements
Part D Prescribing Physician's Supporting Statement
Questions about the Grievance, Coverage Decisions or Appeals
Contact numbers to inquire about the status of a grievance,coverage decision or an appeal
Appointment of Representation
Obtaining an aggregate number of Part C grievances and appeals

Instructions for
Filing a Grievance or Complaint about Medical Care or Part D Prescription Drugs

Located in Chapter 9, Section 10 of the EOC: Making Complaints

To submit a grievance verbally, contact Member Services at:
918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a formal grievance in writing, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Coordinator
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

Part C Coverage Decision Requests about Medical Care

Located in Chapter 9, Section 5 of the EOC: Your Medical Care: How to ask for a Coverage Decision or make an Appeal.

To request a coverage decision verbally, contact Member Services at 1-800-642-8065 or 918-594-5323 (local); TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a request in writing, send to:
CommunityCare Senior Health Plan
Attn: Member Services
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-594-5250

In person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

Coverage Decision Requests about Part D Prescription Drugs

Located in Chapter 9, Section 6 of the EOC: "How to ask for a coverage decision or make an appeal"

To request a coverage determination verbally, contact the Pharmacy Help Desk at 1-800-642-8065 or 1-877-293-8628, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a request in writing, send to:
CommunityCare Senior Health Plan
Attn: Pharmacy Help Desk
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4309

In person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

A letter or the standardized Medicare Prescription Drug Coverage Determination Form may be used to submit a request. Click on the link to print this form.

Enrollees:

Coverage Determination Request Form

Providers:

Coverage Determination Request Form

Making an Appeal about Part C Medical Care

Located in Chapter 9, Section 5 of the EOC: How to ask for a Coverage Decision or make an Appeal.

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. A standardized appeal request form is available. However, you may submit your request in any format. To print this form, click on the following link:

Part C Appeal Request Form

To submit an appeal request in writing, send to:

CommunityCare Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327

Requests for appeals must be in writing unless the request is for a fast or expedited decision. Members must file their appeal request within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Member Services at 1-800-642-8065 or 918-594-5323 (local); TTY/TDD: 1-800-722-0353. Monday - Friday 8:00 am to 8:00 pm central time.

Fax Number: 918-879-4048

In Person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who make the unfavorable decision. When we complete the appeal review, we will give you our decision in writing.

Redetermination (Appeal) for Part D Prescription Drugs

Located in Chapter 9, Section 6 of the EOC: How to ask for a coverage decision or make an appeal

Requests for Appeal Level 1 redeterminations must be in writing unless the request is for a fast or expedited decision.

Members must file their appeal within 60 calendar days from the date included on the notice of the coverage decision. Exceptions may be granted if you have a good reason for missing the deadline.

To submit a fast appeal verbally, contact Member Services at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a standard appeal in writing, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Coordinator
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

A standardized Redetermination Request Form is available. However, you may submit your request in any format.

Part D Appeal Request Form

Prior Authorization or other Utilization Management Requirements for Part D Prescription Drugs

Located in Chapter 5, Section 5 of the EOC: There are restrictions on coverage of some drugs

For prescribing physicians to submit a prior authorization request verbally, contact the Pharmacy Help Desk at 1-800-642-8065 or 1-877-293-8628, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

To submit a prior authorization in writing, send to:
CommunityCare Senior Health Plan
Attn: Pharmacy Help Desk
P.O. Box 3327
Tulsa, OK 74101-3327

Fax Numbers: 918-879-4309

Physicians may use the attached Prescription Authorization Form to request prior authorization. Click on the link to print a copy of this form to take to your physician.

Coverage Determination Request Form

Prescribing Physician's Supporting Statement for Part D Prescription Drugs

Chapter 9, Section 6 of the EOC: How to ask for a coverage decision or make an appeal

There is no standardized form for a prescribing physician to use to present supporting statements or documents.

For a prescribing physician to submit a supporting statement verbally, contact the Pharmacy Help Desk at 1-800-642-8065 or 1-877-293-8628, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m.

To submit supporting documents in writing, send to:
CommunityCare Senior Health Plan
Attn: Pharmacy Help Desk
P.O. Box 3327
Tulsa, OK 74101-3327

Fax Numbers: 918-879-4309

Questions about the Grievances, Coverage Decisions and Appeals

Questions about grievances, coverage decisions and appeals can be answered by our Member Services Department.

Contact Member Services at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

Contact numbers for Grievances, Coverage Decisions and Appeals

For Coverage Decisions about Part D Prescription Drugs: contact the Pharmacy Help Desk at 1-800-642-8065 or 1-877-293-8628, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

For Coverage Decisions about Medical Care: contact Member Services at 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

For Part D or Part C Appeal status: contact Member Services at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

For Part D or Part C Grievance status: contact Member Services at 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

Appointment of Representation

Located in Chapter 9, Section 4 of the EOC: A guide to the basics of coverage decisions and appeals

If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this person to represent you. A completed standardized form is required in order to appoint a representative. To print this form, click on the following link:

Appointment of Representative Form

This form is also available on Medicare's website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.

Instructions for completing the Appointment of Representative form:

Section 1:	The member (beneficiary) completes the requested information in Section I including the name of the individual they appoint as their representative. The beneficiary's signature is required.
Section 2:	This section is completed by the individual the beneficiary has named as their representative. The representative's signature is required.
Section 3 and Section 4:	These sections may not apply. See page 2 of the form for further information.

To submit a completed Appointment of Representation Form, send to:
CommunityCare Senior Health Plan
Attn: Grievance and Appeals Coordinator
P.O. Box 3327, Tulsa, OK 74101-3327

Fax Number: 918-879-4048

In person: Williams Center Tower II, Two West Second Street, Suite 100, Tulsa, Oklahoma 74103 (Corporate Office) or 4720 S. Harvard, Tulsa, OK 74135 (Senior Center)

Obtaining an aggregate number of Part C grievances and appeals

For information on how to obtain an aggregate number of grievances and appeals, contact Member Services at: 918-594-5323 or 1-800-642-8065, TTY/TDD: 1-800-722-0353, Monday - Friday 8:00 a.m. to 8:00 p.m. central time

Disclaimers

You may join or leave a plan only at certain times. Please call Senior Health Plan at the telephone number listed in the previous section of this web page or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call this number 24 hours a day, seven days a week.
You can join Senior Health Plan if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll in Senior Health Plan unless they are members of our organization and have been since their dialysis began.
Senior Health Plan has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or search the Senior Health Plan provider directory on this website. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither Senior Health Plan nor Original Medicare will pay for these services.
You must continue to pay your Medicare Part B premium, even if the Senior Health Plan premium is $0.

Senior Health Plan has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a current Pharmacy Network List or search the Senior Health Plan provider directory on this website.
As a member of Senior Health Plan, you have the right to make complaints and to ask us to reconsider decisions we have made. A complaint is also called a "grievance". A coverage decision that involves your medical care is called an "organization determination". When a coverage decision involves a Part D medication, it is called a "coverage determination". When you ask us to reconsider a decision we made, it means you are asking for an "appeal". To learn more, click on the links below. Additionally, Senior Health Plan Member Services can help if you have any questions or concerns.