Pharmacy-related Grievances, Appeals, & ExceptionsQuality Assurance Policies and ProceduresCCA has both a Quality Management Program and a Medication Therapy Management (MTM) Program. For more information, please contact our Member Services Department toll-free at 1-866-610- 2273 (SCO members) or 1-800-311-9529 (CCC members), Monday–Friday, 8:00AM–5:00PM. TTY users please dial 1-866-322-7357. Pharmacy-related Grievances, Appeals, and Exceptions InformationYou may ask us to cover a drug if it is not on the formulary. You may ask us to cancel limits or restrictions on a drug. For example, certain drugs require a limit on the amount we can cover. If your drug has a limit quantity, you can ask us to waive the limit and cover more. YOUR PRESCRIPTION DRUG COVERAGE (PART D)APPEALS /GRIEVANCESWhat do I do if I have complaints about my Part D prescription drug benefits? Grievance, Coverage Determination and Appeals ProcessesThis section gives a summary of the rules for making complaints in different types of situations. A complaint will be handled as a griev ance, coverage determination, or an appeal, depending on the subject of the complaint. What is a grievance?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 the Commonwealth Care Alliance drug benefits or one of our network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with things such as waiting times when you fill a prescription, the way your network pharmacist or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of a network pharmacy. What is a coverage determination?Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. You, your physician or your appointed representative may file a coverage determination, including an exception, by: TelephoneSCO Toll Free: 1-866-610-2273
Fax617-426-3097 Commonwealth Care Alliance
How do I file a coverage determination, including an exception?You, your physician, or your appointed representative may file a coverage determination in the following ways: TelephoneSCO Toll Free: 1-866-610-2273
Fax617-426-3097 Commonwealth Care Alliance
Click here to download a Model Coverage Determination Form Click here to download Model Form Instructions for Coverage Determination What is an appeal?An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You would file an appeal if you want us to reconsider and change a decision we have made about what Part D prescription drug benefits are covered for you or what we will pay for a prescription drug. How do I file a grievance or appeal?You, your physician, or your appointed representative may file a grievance or appeal in the following ways: TelephoneSCO Toll Free: 1-866-610-2273
Fax617-426-3097 Commonwealth Care Alliance
If we deny part, or all, of your request in our coverage determination, you may ask us to reconsider our decision. This is called an “appeal” or “request for redetermination”. Please call us if you need help with filing your appeal. You may ask us to reconsider our coverage determination, even if only part of our decision is not what you requested. When we receive your request to reconsider the coverage determination, we give the request to people at our organization who were not involved in making the coverage determination. This helps ensure that we will give your request a fresh look. You may also mail your request for redetermination to: Commonwealth Care AllianceMember Services Department
Or Fax617-426-3097 Where do I find additional information about grievances, coverage determinations, and appeals?Please see your Evidence of Coverage (EOC) for more information on our grievance, coverage determination, and appeals process. If you have any questions about any of these processes, or if you want to inquire about the status of a grievance, coverage determination or appeal request, you, your physician or your appointed representative may contact us at: SCO Toll Free: 1-866-610-2273
How do I appoint a representative?If you need someone to file a grievance, coverage determination 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. If you are requesting a coverage determination through an appointed representative, you should complete form (CMS-1696) and mail it to: Commonwealth Care AllianceMember Services Department 30 Winter Street, 11th floor Boston, MA 02108 Or Fax617-426-3097 If you have any questions about naming your appointed representative, you can call us at:SCO Toll Free: 1-866-610-2273
Last updated 06/06/2008 |
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