CareMore Cal MediConnect

Appeals

Medicare Part C and Medi-Cal Appeals (not Part D drugs)

What is an appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. We also call this a Reconsideration. If you or your doctor or other provider disagrees with our decision, you can appeal.

In most cases, you must start your appeal at Level 1.

What is a Level 1 Appeal?

A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing.

We must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to.

  • However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter

If your health requires it, ask us to give you a "fast appeal"

If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so.

  • A fast appeal means we will give you an answer within 72 hours
    • You can get a fast appeal only if you are asking for an item or service you have not yet received. (You cannot get a fast appeal if you are asking us to pay you back for something you have already paid for.)
    • You can get a fast appeal only if using the standard deadlines could cause serious harm to your health or hurt your ability to function
    • If your doctor tells us that your health requires a "fast appeal," we will automatically agree to give you a fast appeal, and the letter will tell you that

    If you ask for a fast appeal on your own (without your doctor's support), we will decide whether you get a fast appeal. Fast appeals can be submitted by calling Member Services or by submitting a written request.

    If we decide to give you a standard decision, we will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision. You can file a "fast complaint" and get a decision within 24 hours.

    • We will review your request and if we decide that your medical condition does not meet the requirements for a fast appeal, we will send you a letter that says so (and we will use the standard deadlines instead)

When can an appeal be filed?

You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are you had a serious illness or we gave you the wrong information about the deadline for requesting an appeal.

Where can an appeal be filed?

Fast appeals can be submitted by calling or in writing. Other appeals (standard) must be submitted in writing:

Download the CareMore Cal MediConnect Plan GRIEVANCE FORM

Complete the Online CareMore Cal MediConnect Plan GRIEVANCE FORM

  • Mailing your request to:
    • CareMore
      Attn: Appeals and Grievances
      12900 Park Plaza Drive, Ste #150
      MS-6151
      Cerritos, CA 90703
  • Faxing to: 1-888-426-5087
  • Calling Member Services at 1-888-350-3447 (TTY: 711) Monday - Friday 8 a.m. to 8 p.m. PST, except on holidays, to:
    • Request an appeal
    • Get a status on a filed appeal
    • Learn more about our appeal process

Please note: All Medicare Part C and Medi-Cal appeals and grievances may be filed by telephone.

What do I include with my appeal?

  • Your name, address and member ID number
  • Your reasons for appealing
  • Any evidence you wish to attach, such as supporting medical records, doctors' letters or other information that explains why your plan should cover the service

Call your doctor if you need this information to help you with your appeal. You may send in this information or give us this information in person if you wish.

Medicare Part D Appeals

What is an appeal?

An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. We also call this a Redetermination. If you or your doctor disagrees with our decision, you can appeal.

In most cases, you must start your appeal at Level 1.

What is a Level 1 Appeal?

A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing.

We must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a "fast appeal." If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.

If your health requires it, ask for a "fast appeal"

  • If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a "fast appeal"
  • The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision"

When can an appeal be filed?

You, your doctor or prescriber, or your representative may put your request in writing and mail or fax it to us within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Expedited Medicare Part D Appeals may be filed by telephone.

Where can a Medicare Part D appeal be filed?

  • You can request a Medicare Part D appeal by filling out a Request for Redetermination of Medicare Prescription Drug Denial form.
  • You can mail your request to:
    • CareMore
      Attn: Appeals and Grievances
      12900 Park Plaza Drive, Ste #150
      MS-6151
      Cerritos, CA 90703 
  • You can fax your request to 1-888-426-5087
  • You can call Member Services at 1-888-350-3447 (TTY: 711) Monday - Friday 8 a.m. to 8 p.m. PST, except on holidays, to:
    • Submit a fast appeal
    • Get a status on a filed appeal
    • Learn more about our appeal process

Please note: Expedited Medicare Part D Appeals may be filed by telephone. Standard Medicare Part D Appeals must be filed in writing.

Who can file an appeal?

  • You may file an appeal
  • Someone else may file the appeal for you on your behalf

Appointing a representative

Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you but first you must complete an Appointment of Representative form. The form gives the other person permission to act for you. All forms must include:

  • Your name, address and phone number
  • Your Medicare Health Insurance Claim Number (HICN) number
  • The name, address and phone number of your representative
  • Include a statement that you are giving permission for the representative to act on your behalf and are giving permission for personal information to be given to your representative
  • Is signed by you and your representative

Include a statement that your representative agrees to act on your behalf.

To get an Appointment of Representative form, call Member Services and ask for one or visit the Medicare website by clicking the link below.

  • If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal

CMS Link to Appointment of Representative form

What happens next?

Medicare Part C Services

If you appeal, we will review the decision. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by an Independent Review Entity outside of CareMore Cal MediConnect Plan.

  • You do not need to request the Level 2 Appeal. We will automatically send any denials (in whole or in part) to the Independent Review Entity. You will be notified when this happens
  • The Independent Review Entity is hired by Medicare and is not connected with this plan
  • You may ask for a copy of your file. 

If you disagree with that decision, you have further appeal rights. You will be notified of those appeal rights if this happens.

Medicare Part D Services

If we say "No" to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity will review our decision.

If you want the Independent Review Entity to review your case, your appeal request must be in writing. The letter we send about our decision in the Level 1 Appeal will explain how to request the Level 2 Appeal. When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. 

The Independent Review Entity is hired by Medicare and is not connected with this plan.

Reviewers at the Independent Review Entity will take a careful look at all of the information from you. The Independent Review Entity will send you a letter explaining its decision.

If you want the Independent Review Organization to review your case, your appeal request must be in writing. Ask within 60 calendar days of the decision you are appealing. If you miss the deadline for a good reason, you may still appeal. You, your doctor or other prescriber or your representative can request the Level 2 Appeal.

To request an appeal with the Independent Review Entity:

  • Mail or fax your request to:
    • MAXIMUS Federal Services
      Part D QIC
      3750 Monroe Avenue, Suite 703
      Pittsford, New York 14534-1302
      FAX: 1-866-825-9507

If you disagree with that decision, you have further appeal rights. You will be notified of those appeal rights if this happens.

Medicaid (Medi-Cal) Services

If you appeal, we will review the decision. If any of the services you requested are still denied after our review, you may request a Level 2 Appeal, which is done by an independent organization that is not connected with the plan. There are two ways to make a Level 2 Appeal for Medi-Cal services and items:

  1. Independent Medical Review (IMR)
  2. State Hearing

Independent Medical Review (IMR)

You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR.

You can apply for an IMR if CareMore Cal MediConnect Plan:

  • Denies, changes or delays a Medi-Cal service or treatment (not including IHSS) because CareMore Cal MediConnect Plan determines it is not medically necessary
  • Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition
  • Will not pay for emergency or urgent Medi-Cal services that you already received
  • Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal

You can ask for an IMR if you have also asked for a State Hearing but not if you have already had a State Hearing on the same issue.

In most cases, you must file an appeal with us before requesting an IMR. See Chapter 9 of your Member Handbook for information about CareMore Cal MediConnect Plan's Level 1 appeal process. If you disagree with our decision, you can ask the DMHC Help Center for an IMR.

  • If your treatment was denied because it was experimental or investigational, you do not have to take part in CareMore Cal MediConnect Plan's appeal process before you apply for an IMR
  • If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC's attention. The DMHC may waive the requirement that you first follow CareMore Cal MediConnect Plan's appeal process in extraordinary and compelling cases

You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time.

To request an IMR:

  • Fill out the Complaint/Independent Medical Review (IMR) Application Form available at http://www.dmhc.ca.gov/FileaComplaint/ConsumerIndependentMedicalReviewComplaint/IndependentMedicalReviewComplaintForm.aspx or call the DMHC Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891
  • If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents
  • Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form at http://www.dmhc.ca.gov/dmhc_consumer/pc/pc_forms.aspx or by calling the DMHC Help Center at 1-888-466-2219. TDD users should call 1-877-688-9891
  • Mail or fax your forms and any attachments to:
    • Help Center
      Department of Managed Health Care
      980 Ninth Street, Suite 500
      Sacramento, CA 95814-2725
      FAX: 1-916-255-5241

For more information about the IMR process, please see Chapter 9 of your Member Handbook.

State Hearing

You can request a State Hearing at any time for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve or we will not continue to pay for a service or item you already have, and we said no to your Level 1 appeal, you have the right to ask for a State Hearing.

In most cases, you have 120 days to ask for a State Hearing after the "Your Hearing Rights" notice is mailed to you. You have a much shorter time to ask for a hearing if your benefits are being changed or taken away. There are two ways to request a State Hearing:

  1. You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved and a detailed reason why you want a hearing. Then you may submit your request one of these ways:
    • To the county welfare department at the address shown on the notice
    • To the California Department of Social Services:
      • State Hearings Division
        P.O. Box 944243
        Mail Station 9-17-37
        Sacramento, California 94244-2430
    • To the State Hearings Division at fax number 1-916-651-5210 or 1-916-651-2789
  2. You may make a toll-free call to request a State Hearing at the following number. If you decide to make a request by phone, you should be aware that the phone lines are very busy.
    • Call the California Department of Social Services at 1-800-952-5253. TDD users should call 1-800-952-8349.

For more information about the State Hearing process, please see Chapter 9 of your Member Handbook.

The California Department of Managed Health Care

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-888-350-3447; TTY: 711 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site has complaint forms, IMR application forms and instructions online.

Link to California Department of Managed Health Care