A Healthy CollaborationSM

Appeals

If we deny all or part of your coverage determination request, you or your appointed representative may ask us to reconsider our decision. This is called an appeal or re-determination.

Appointing a Representative

Patients can name a relative, friend, advocate, attorney, doctor, or someone else to act on their behalf as their representative. The Centers for Medicare and Medicaid Services (CMS) requires written notification from both the member and the representative. Print the Appointed a Representative form. Once the form is filled out in its entirety fax it to the Beneficiary Services Unit at 866-684-5378.

What is the deadline for submitting an appeal?

You must file your appeal within 60-days of the date on the letter that is attached to the coverage determination notification. If you happen to miss the 60-day deadline, we may grant you an extension on a case-by-case basis.

How quickly will Community CCRxSM respond after my appeal is submitted?

Standard appeals must be completed within seven days of receiving your appeal request.

Expedited appeals must be completed within 72 hours of receiving your appeal request.

How do I file my appeal?

To file a standard appeal, you can send the appeal request to us in writing at:

Community CCRx
Appeals/Coverage Determinations
P.O. Box 391197
Solon, OH 44139-3911

You can fax your appeal request to us at: 1-866-868-0858.

You may also file an appeal by phone. To file an appeal, or if you have any general questions about the appeals process, call us at 1-866-316-6049 (TTY/TDD users call 1-866-684-5351).

What if I need my medicines sooner than seven days?

This would be considered an expedited appeal. To file an expedited appeal, call us at 1-866-316-6049 (TTY/TDD users call 1-866-684-5351).

How do I provide you additional information to support my appeal?

Community CCRx will gather all the necessary information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you and/or your doctor. You also have the right to obtain and include additional information as part of your appeal. This information may include documents you may already have, or your doctor’s written opinion or records. Please note that you may need to give your doctor a written request for information. You can give us this additional information in any of the following ways:

Send information by mail to:

Community CCRx
Appeals/Coverage Determinations
P.O. Box 391197
Solon, OH 44139-3911
Fax information to: 1-866-868-0858
Or call us at: 1-866-316-6049 (TTY/TDD users call 1-866-684-5351).

What happens if my appeal is denied?

If we deny all or part of your appeal request, you or your appointed representative may request a review by an independent review entity (IRE). The IRE is contracted directly with the federal government and is not affiliated with Community CCRx in any way. You can access a reconsideration form here.

Please refer to your Evidence of Coverage, section on Appeals, for more information on what to do next.

S5803_09P0008_v4 (09/2009) Last Updated: 09/09/2022

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