How to File an Appeal or Grievance

Coverage Determinations including Exception Requests, Grievances, and Appeals

OneCare (HMO SNP) provides coverage determinations and reviews exception requests, grievances, and appeals to ensure you get answers to your concerns or problems. For more information on our process, please see Chapter 9 of your Evidence of Coverage book.

Part C Coverage Determinations

As a OneCare member, you may ask for medical coverage determination of a service you wish to receive, or for payment of a service you have already received.

To ask for a coverage determination, please call the OneCare Customer Service Department toll-free at 1-877-412-2734. TTY/TDD users please call 1-800-735-2929. You may also send your request in writing by fax to 1-714-246-8711, or send by mail to:

OneCare Customer Service
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868

Part C and D Grievances

If you have concerns or problems with OneCare which are not about coverage decisions, payments or service requests, you have the right to file a grievance. Common reasons include wait time on the phone, rudeness by someone, an incident at a network pharmacy or in waiting rooms or your doctor’s office. You must file your grievance within 60 days of the date of the incident. The filing timeline may be extended if there is good cause for the delay.

You or your representative may file a grievance in person or by calling the OneCare Customer Service Department, 24 hours a day, 7 days a week, at 1-877-412-2734. (TTY/TDD users please call 1-800-735-2929.) You may also fax the written grievance to 1-714-481-6499, or send by mail to:

Grievance and Appeals Resolution Services
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868

Once OneCare has received your file, you will be mailed the name and phone number of the Resolution Specialist who is handling your case and the estimated time for a written response. A written resolution letter will be mailed to you within 30 days of OneCare getting your grievance.

Fast or Expedited Grievance

You have the right to request an expedited (fast/rushed) review if you disagree with OneCare’s decision to use an extension on your request for an organization determination or reconsideration, or OneCare’s decision to process your expedited request as a standard request. In such cases, OneCare will notify you of the outcome within 24 hours of receipt of the request.

If you wish to have someone represent you other than your doctor, you must complete the Appointment of Representative Form and include the form with your grievance, coverage or drug exception request, or your appeal.

Part C Appeals

As a member of OneCare, you, your doctor or your representative can file an appeal if OneCare makes a decision to not pay for, not approve or stop a service you think should be covered or provided to you. This could include denials for referrals to see a specialist, for durable medical equipment or involving payment for services you received or believe you should receive under the OneCare program (including co-payments and billing issues or reimbursement).

You must file your appeal within 60 days of the date of the notice of denial. The filing timeline can be extended if you show good cause for the delay in filing your appeal. To appeal a decision, please contact the OneCare Customer Service Department by calling 1-877-412-2734, 24 hours a day, 7 days a week (TTY/TDD users call 1-800-735-2929), or visit our office Monday through Friday, from 8 a.m. to 5 p.m., or fax the grievance to 1-714-481-6499. You can also send your written appeal to:

Grievance and Appeals Resolution Services
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868

OneCare will review your appeal and send you a letter telling you the review decision within 30 days of receiving your pre-service appeal. If you are appealing a payment denial, OneCare will review and send you a letter telling you the review decision within 60 days of receiving your appeal. You or your representative can also provide information about your complaint in person about your appeal by contacting our OneCare Customer Service Department.

If you think your health could be seriously harmed by waiting for a decision about a service, you can request a faster decision, which is issued within 72 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include, when necessary, an independent review entity, such as hearings before an Administrative Law Judge, review by the Medicare Appeals Council and judicial review.

If you wish to have someone represent you other than your doctor, you must complete the Appointment of Representative Form and include the form with your appeal.

Early Discharge Appeals Are Sent to Quality Improvement Organization (QIO)

The QIO can also review appeals when you think you are being discharged too early from:

  • Hospital
  • Skilled nursing facility
  • Services from a home health agency
  • Certified outpatient rehabilitation facility

The QIO for CalOptima OneCare (HMO SNP) program is Livanta. You can contact Livanta directly by calling 1-877-588-1123. TDD/TTY users can call 1-855-887-6668. Livanta’s phone lines are available Monday through Friday 9 a.m.-5 p.m. local time, Saturday through Sunday 11 a.m.-3 p.m. local time. An answering machine accepts after hours messages. Calls are returned the next day. Livanta’s website is http://bfccqioarea5.com. You may fax your complaint to 1-855-694-2929.

You may write to Livanta at:

Livanta, LLC
9090 Junction Dr., Suite 10
Annapolis Junction, MD 20701

You will receive information on how to contact the QIO when you get denials for these services. You can also call OneCare Customer Service for assistance at 1-877-412-2734, 24 hours a day, 7 days a week. TDD/TTY users can call 1-800-735-2929.

Quality of Care Issues

You can file a complaint about the quality of care provided by:

  • OneCare providers
  • Inpatient or outpatient hospitals
  • Emergency departments
  • Skilled nursing facilities
  • Home health agencies
  • Ambulatory surgical centers

There is no specific timeline in which you must file a complaint related to a quality of care issue. Some quality of care issues include: wrong medication, unnecessary surgery, diagnostic testing, inadequate care, or misdiagnosis by any Medicare hospital or doctor under the OneCare program.

You can send your complaint through the OneCare Grievance and Appeals Resolution Services department or with a Quality Improvement Organization (QIO) designated by Medicare.

The QIO for the CalOptima OneCare (HMO SNP) program is Livanta. You can contact Livanta directly by calling 1-877-588-1123. TDD/TTY users can call 1-855-887-6668. Livanta’s website is http://bfccqioarea5.com. You may fax your complaint to 1-844-420-6672 for quality of care concerns.

You may write to Livanta at:

Livanta, LLC
9090 Junction Dr., Suite 10
Annapolis Junction, MD 20701

Part D Exception Requests

You can ask OneCare to make an exception to our coverage rules. Below are some of the exceptions that you can ask for:

  1. You can ask us to cover a drug even if it is not on our approved formulary list.
  2. You can ask us not to restrict or limit the amount of a drug that we will cover, even if your drug has a quantity limit.

To request an exception to our drug coverage, please call the OneCare Customer Service Department at 1-877-412-2734 for assistance. (TTY/TDD users please call 1-800-735-2929.) You may also submit your request in writing by fax to 1-714-246-8711, or send by mail to:

OneCare Customer Service
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868

You should contact us to ask for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your doctor to support your request. You can request an expedited (rushed) review if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s support statement. If your request to expedite (rush) is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s support statement.

Part D Appeals

As a member, you can file an appeal if OneCare makes a decision to not pay for, not approve or stop a service you think should be covered or provided to you. This could include denials for drugs or involve payment for services you received or believe you should receive under the OneCare pharmacy program (including co-payments and billing issues or reimbursement). You or your appointed representative must file the appeal within 60 calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice).

Members and providers may use Medicare's Model Coverage Determination Request Form

To appeal a decision, you may call OneCare Customer Service Department toll-free at 1-877-412-2734, 24 hours a day, 7 days a week (TTY/TDD users please call: 1-800-735-2929), or visit our office Monday through Friday, from 8 a.m. to 5 p.m., or fax the appeal to 1-714-481-6499. You can also send your appeal in writing to:

Pharmacy Management
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868

We will review your appeal and send you a letter telling you our decision within 7 days of receiving your appeal request. If you think your health could be seriously harmed by waiting for a decision about the drug, you can request a faster decision which is issued within 24 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include an independent review entity, hearings before an Administrative Law Judge, review by the Medicare Appeals Council and judicial review.

If you wish to have someone represent you other than your doctor or prescriber of your drug(s), you must complete the Appointment of Representative Form and include the form with your coverage or drug exception request, or your appeal.

Complaints about your Medi-Cal Coverage

In addition to filing complaints about your Medicare coverage and/or services, you also have the right to file complaints with CalOptima or with the Department of Social Services Hearing Office about your Medi-Cal coverage. To find out more about your Medi-Cal complaint and State Hearing rights, refer to your OneCare Evidence of Coverage. You may also contact OneCare Customer Service at 1-877-412-2734, Monday through Friday, from 8 a.m. to 5:30 p.m. for more information or assistance in filing a complaint or State hearing. (TTY/TDD users please call 1-800-735-2929.)

Date Revised September 20, 2016

To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_WEB1004 Approved (11/15/16)

OneCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract. Enrollment in OneCare depends on contract renewal. Eligible beneficiaries can enroll at any time. Eligible beneficiaries must have Part A and Part B to enroll in the plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Other Pharmacies/Physicians/Providers are available in our network. Medicare beneficiaries may also enroll in OneCare (HMO SNP) through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Medicare has neither reviewed nor endorsed this information. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. OneCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This information is available for free in other languages. Please call our customer service number at 1-877-412-2734, 24 hours a day, 7 days a week. TDD/TTY users should call 1-800-735-2929.

Download the free Adobe Reader.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website,
click here.

Language
Text Size