A Healthy CollaborationSM

Appeals and Grievances for Medical Coverage

Appeals and Grievances
The following procedures for Appeals and Grievances apply to Medicare Advantage plans and are endorsed by CMS and must be followed by the plan in identifying, tracking, resolving, and reporting all activity related to appeals or grievances.

Member Appeals

Who can file an Appeal regarding healthcare decisions?
An appeal may be filed by any of the following:

  • A member, including the member’s authorized representative
  • A member’s physician, an ancillary provider or a hospital representing the member
  • A legal representative of the deceased’s estate

What is an Appeal?
An appeal is a request from a member to the health plan to reconsider a decision, also called an organizational determination. An appeal is the start of a process in response to a decision made by the health plan to:

  • Discontinue or reduce services
  • Pay or not to pay for services, that a member believes should be furnished

When can a healthcare Appeal be filed?
A member has sixty (60) days to file an appeal regarding medical care:

  • That has not been approved
  • That is being discontinued or reduced
  • That would pay or not pay for services already furnished

An appeal may be received verbally or in writing.

Where can an appeal be filed?
An appeal may be filed with any of the following organizations:

  • Centers for Medicare and Medicaid Services (CMS)
  • The Social Security Administration (SSA)
  • The Railroad Bureau (RRB)
  • The Health Plan

All employees and affiliates of a health plan are required to know where to direct member appeals.

Why file an appeal?
A member may file an appeal when an adverse decision is made that they want overturned, as well as to protect their rights.

Fast Decisions/Expedited Appeals
A member may request a decision be decided more quickly. The health plan must first determine if the appeal meets the following criteria for expedited appeals:

  • If the standard process and timeliness could jeopardize the life of health of the member, or
  • The likelihood of member’s ability to regain maximum function is reduced.

Member Grievances

Who can file a healthcare Grievance?

  • A member, including the member’s authorized representative
  • A member’s physician, an ancillary provider or a hospital representing the member, or
  • A legal representative of the deceased’s estate.

What is a Grievance?
A grievance is dissatisfaction with any aspect of the Health Plan that does not involve an organizational determination - the approval or denial of services - by the Health Plan.

When can a Grievance be filed?
A member may file a grievance at any time. The grievance may be verbal or written.

Expedited Grievance
A member may request a fast review or expedited grievance if he or she disagrees with the Health Plan’s decision not to process the request for an expedited organization determination or an expedited reconsideration.

Where can the Grievance be filed?
A grievance may be filed with ay of the following organizations: 

  • Centers for Medicare and Medicaid Services (CMS)
  • The Social Security Administration (SSA)
  • The Health Plan.

All employees and affiliates of the Health Plan are required to know where to direct member grievances.

Why file a Grievance?
A grievance may be filed anytime a member is dissatisfied with any aspect of the health plan.

How to File a Grievance:
If you have a grievance, we encourage you to first call a Member Services Representative. We will try to resolve any complaint that you might have over the phone.

If you wish to send a formal written grievance, mail the grievance to:

Today’s Options
c/o Appeals and Grievances 
PO Box 742528
Houston, TX 77274

Be sure to include the following:

  • Full name 
  • Address
  • ID number
  • Signature 
  • Date
  • Summary of the problem
  • Statement of action you are requesting

Today’s Options Member Services
1-866-568-8921; TTY/TDD: 1-800-958-2692 from 8 AM to 8 PM, 7 days a week

If you have prescription drug coverage as part of your Medicare Advantage plan, you are also entitled to certain rights.

What to do if you have complaints about your prescription drug coverage?
We encourage Today’s Options members to contact us with questions, concerns, or problems related to prescription benefits. Please call us at 1-866-568-8921; TTY 1-800-958-2692 to discuss your concerns. Complaints and inquiries are grouped by type. Federal law guarantees Today’s Options members’ rights to make complaints regarding concerns or problems with any part of the plan. The Medicare program has helped set the rules about what’s needed to make a complaint, and what Today’s Options is required to do when we receive a complaint. If a complaint is filed, we must be fair in how we handle it. A Today’s Options member may not be disenrolled from Today’s Options or penalized in any way for making a complaint.

What are appeals and grievances?
Today’s Options members have the right to make a complaint regarding concerns or problems related to coverage or care. “Appeals” and “grievances” are the two different types of complaints that can be filed.

An “appeal” is the type of complaint a member can make when the member wants Today’s Options to reconsider and change a decision we have made about what prescription drug benefits are covered or what we will pay for a prescription drug. For example, if we refuse to cover or pay for a prescription drug a member thinks we should cover, an appeal can be filed. If Today’s Options refuses to provide a prescription drug the member thinks should be covered, the member can file an appeal. If Today’s Options reduces or cuts back on the prescription drugs a member has been receiving, the member can file an appeal. If the member thinks we are stopping prescription drug coverage too soon, the member can file an appeal.

A “grievance” is the type of complaint a member can make if the member has any other type of problem with Today’s Options or one of our network pharmacies. For example, a member should file a grievance if the member has problems with things such as waiting times when filling a prescription, the way the network pharmacist or others behave, being able to reach someone by phone or getting the needed information, or the cleanliness or condition of a network pharmacy.

Appeals can be filed in the following situations:

  • If a member is not getting a prescription drug the member believes may be covered by Today’s Options.
  • If a member receives a Part D prescription drug that the member believes may be covered by Today’s Options, but we have refused to pay for it.
  • If we will not provide or pay for a Part D prescription drug that a member’s doctor has prescribed because it is not on our list of covered drugs (called a “formulary”). A member can request an exception to our formulary.
  • If the member disagrees with the amount that we require to pay for a Part D prescription drug a member’s doctor has prescribed. A member can request an exception to the co-payment we require to pay for a drug.
  • A member requests an exception to our formulary or to the co-payment for a drug and we denied the request.
  • If a member is being told that coverage for a Part D prescription drug will be reduced or stopped.
  • If there is a requirement that a member try another drug before we pay for the drug the member’s doctor prescribed, or if there is a limit on the quantity (or dose) of the drug and the member disagrees with the requirement or dosage limitation.
  • A member bought a drug at a pharmacy that is not in our network and the member wants to request reimbursement for the expense.
  • We do not make a decision on a member’s request within the required time frame.

Requesting a prescription drug coverage appeal from Today’s Options.
If a member is having a problem getting a Part D benefit or payment for a Part D prescription drug that the member has already received, the member can request an appeal. After we have made the initial coverage determination, there are five levels of appeal. At each level, the request is considered and a decision is made. If the member is unhappy with the decision, the member may be able to ask for the next level of appeal if the member wants to continue requesting the benefit or payment.

What kinds of prescription drug decisions can be appealed?
A member can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. A member may also appeal our decision not to reimburse the payment for a Part D drug. In addition, if the member thinks we should have paid or reimbursed more than the member received, or the amount paid is more than the member is supposed to pay under the plan, the member can appeal. Finally, if we deny an exception request, the member can appeal. Here are some examples of situations where a member might want to file an appeal:

  • If the member is not getting a prescription drug that the member believes may be covered by Today’s Options.
  • If the member has received a Part D prescription drug believed to be covered by Today’s Options, but we have refused to pay for the drug.
  • If we will not provide or pay for a Part D prescription drug that the member’s doctor has prescribed because it is not on our list of covered drugs (called a “formulary”). A member can request an exception to our formulary.
  • If the member disagrees with the amount that we require to pay for a Part D prescription drug a doctor has prescribed, the member can request an exception to the co-payment we require you to pay for a drug.
  • The member has requested an exception to our formulary or to the co-payment for a drug and we have denied.
  • If a member is being told that coverage for a Part D prescription drug will be reduced or stopped.
  • If there is a requirement that a member try another drug before we pay for the prescribed drug, or if there is a limit on the quantity (or dose) of the drug and the member disagrees with the requirement or dosage limitation.
  • A member bought a drug at a pharmacy that is not in our network and the member wants to request reimbursement for the expense.
  • We do not make a decision on a member’s request within the required time frame.

Please Note: If we approve an exception request for a non-formulary drug, the member cannot request an exception to the co-payment we require to pay for the drug.

How does the prescription drug appeals process work?
There are five levels to the appeals process. Here are a few things to keep in mind as you read the description of these steps in the appeals process:

Moving from one level to the next. At each level, the request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in the member’s favor (giving some or all of what the member asked for), or it may be completely denied (turned down). If the member is unhappy with the decision, there may be another step to get further review of the request. Whether the member is able to take the next step may depend on the dollar value of the requested drug or on other factors.

“Initial decision” vs. “making an appeal.” Whenever the member asks for a Part D benefit, the first step is called an “initial decision” or a “coverage determination.” If the member is unhappy with the initial decision, the member can ask for an appeal, which is called a redetermination.

Members may send to:
Community CCRx
Attn: Coverage Determination
P.O. Box 391197
Solon, OH 44139-3911

Or by fax to 1-866-868-0858. There are also four other levels of appeal that a member may request.

Who makes the decision at each level. A member can make a request for coverage or payment of a Part D prescription drug directly to Today’s Options. We review this request and make an initial decision. If our initial decision is to turn down the request (in whole or in part), the member can go on to the first level of appeal by asking us to review our initial decision. If the member is still dissatisfied with the outcome, the member can ask for further review. The appeal is then sent outside of Today’s Options, where people who are not connected to us conduct the review and make the decision. To request an external appeal, members may send Medicare’s Reconsideration Request Form to:

Today's Options
4888 Loop Central Drive
Suite 700
Houston, TX 77081

Please reference your most recent denial letter to identify the appropriate location to which you should submit your case. If you are unsure of the correct location, you may call us for assistance at 1-866-316-6049 (TTY 1-866-684-5351), from 8 AM to 8 PM, 7 days a week.

After the first level of appeal, all subsequent levels of appeal will be decided by someone who is connected to the Medicare program or the federal court system. This will help ensure a fair, impartial decision.

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Today’s Options. You may do so by filing a written request with Today’s Options:

Today’s Options
c/o Appeals and Grievances
PO Box 742528
Houston, TX 77274

What is the deadline for submitting a prescription drug 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 Today’s Options 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, in writing or by phone, to the Part D plan that delivers your prescription drug benefits at:

Community CCRx Part D Coverage Determinations/Appeals (about your Part D Prescription Drugs)
CALL 1-866-316-6049. Calls to this number are free.
TTY/TDD 1-866-684-5351. This number requires special telephone equipment.
Calls to this number are free.
FAX 1-866-868-0858
WRITE Community CCRx
Attn: Coverage Determination
P.O. Box 391197
Solon, OH 44139-3911

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:

Community CCRx Part D Coverage Determinations /Appeals (about your Part D Prescription Drugs)
CALL 1-866-316-6049. Calls to this number are free.
TTY/TDD 1-866-684-5351. This number requires special telephone equipment.
Calls to this number are free.
FAX 1-866-868-0858
WRITE Community CCRx
Attn: Coverage Determination/Appeals
P.O. Box 391197
Solon, OH 44139-3911

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 Today’s Options 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.

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