A Healthy CollaborationSM

Grievances

It is Community CCRx's policy to provide timely responses to Grievances.

Appoint a Representative

You can name a relative, friend, advocate, attorney, doctor, or someone else to act on your behalf as your 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 a grievance?

A grievance is different from an appeal because usually it will not involve complaints regarding coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits. Instead, the following types of problems might lead to you file a grievance:

  • If you feel that you are being encouraged to disenroll from Community CCRxSM
  • Problems with the quality of customer service you receive
  • Problems with how long you have to spend waiting on the phone or in the pharmacy
  • Disrespectful or rude behavior by pharmacists or other staff
  • Problems with the cleanliness or condition of the pharmacy
  • If you disagree with our decision not to expedite your request for an expedited coverage determination or redetermination
  • You believe our notices and other written materials are difficult to understand
  • Failure of Community CCRx to make a decision within the required time frame
  • Failure of Community CCRx to forward your case to the independent review entity if we do not make a decision within the required time frame

The Grievance Process

A grievance is different from an appeal because usually it will not involve issues regarding coverage or payment for Part D prescription drug benefits. Concerns about our failure to cover or pay for a certain drug should be addressed through the appeals process.

Filing a grievance with Community CCRx

If you have a grievance, we encourage you to first call Customer Service at 1-866-684-5353 (TTY/TDD users call 1-866-684-5351) 8 a.m. to 8 p.m., every day.

We will try to resolve any complaint that you might have over the phone. If you request a written response to your phone complaint, we will respond to you in writing. If we cannot resolve your complaint over the phone, we have a formal procedure to review your complaints. We call this the Community CCRx Grievance Process.

You may file a grievance by telephone, fax, or through the mail, no later than 60 days after the event that caused the grievance. When you file a written grievance you will receive a written confirmation that your grievance was received. All written grievances will be responded to in writing no later than 30 days from the date that the grievance was received by Community CCRx.

If your grievance involves a refusal by Community CCRx to grant your request for an expedited coverage determination or an expedited redetermination, and you have not yet received the medication that is in dispute, you may file an expedited or “fast” grievance. To file a “fast” grievance, please contact the Customer Service at 1-866-684-5353 (TTY/TDD users call 1-866-684-5351) 8 a.m. to 8 p.m., every day, or fax your written complaint to 1-866-684-5378. In this case, you will receive a response within 24 hours.

Please do not file a “fast” grievance by mail, as we cannot guarantee a response within 24 hours.

In certain circumstances, Community CCRx may extend the 30-day response time by 14 days. We may also extend the timeframe if you request us to do so. Community CCRx may also extend the timeframe if we are in need of additional information. In this case, we only extend the timeframe if the delay is in your best interest and you will receive a letter notifying you of the extension.

You may send a written grievance to the following address:

Community CCRx Grievances
P.O. Box 5205
Rensselaer, NY 12144-5205

You may fax a grievance to the following number: 1-866-684-5378

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

S5803_09P0008_v2 (07/2009) Last Updated: 06/23/2009

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