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 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: |
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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 timeTo 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) |
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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 timeTo 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: Providers: |
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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: To submit an appeal request in writing, send to:
CommunityCare Senior Health Plan
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. 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. |
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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. |
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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. |
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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 |
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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 |
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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 |
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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: 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:
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) |
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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 | ||||||
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