How to File an Appeal or Grievance

Coverage Decisions Including Exception Requests, Grievances And Appeals

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) provides coverage decisions 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 Member Handbook

Part C Coverage Decisions

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

To ask for a coverage decision, please call the OneCare Connect Customer Service department, 24 hours a day, 7 days a week, toll-free at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m., or you may send your request in writing by fax to 1-714-246-8711, or send by mail to:

CalOptima
Attn: OneCare Connect Customer Service
505 City Parkway West
Orange, CA 92868

Part C And D Grievances (Complaints)

If you have concerns or problems with OneCare Connect 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. Grievances related to Medicare Part D must be made within 60 calendar days after you had the problem you want to complain about. 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 Connect Customer Service department, 24 hours a day, 7 days a week, toll-free at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m., or you may send your grievance in writing by fax to 1-714-246-8562, or send by mail to:

CalOptima
Attn: Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868

Once OneCare Connect 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 Connect getting your grievance.

Fast Or Expedited Grievance

You have the right to request an expedited (fast) review if you disagree with OneCare Connect’s decision to use an extension on your request for coverage decision, or OneCare Connect’s decision to process your expedited request as a standard request. In such cases, OneCare Connect 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 Connect, you, your doctor or your representative can file an appeal if OneCare Connect 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 involve payment for services you received or believe you should receive under the OneCare Connect 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 Connect Customer Service department by calling 1-855-705-8823, 24 hours a day, 7 days a week. TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m., or you may send your appeal in writing by fax to 1-714-246-8562, or send by mail to:

CalOptima
Attn: Grievance and Appeals Resolution Services
505 City Parkway West
Orange, CA 92868

OneCare Connect 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 Connect 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 Connect 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, 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 the OneCare Connect 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, from 9 a.m. to 5 p.m. Saturday through Sunday, from 11 a.m. to 3 p.m. 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 Connect Customer Service 24 hours a day, 7 days a week toll-free at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m.

Quality of Care Issues

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

  • OneCare Connect 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 Connect program.

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

The QIO for the OneCare Connect 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, from 9 a.m. to 5 p.m. Saturday through Sunday, from 11 a.m. to 3 p.m. 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

Part D Exception Requests

You can ask OneCare Connect 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 list of covered drugs (formulary).
  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 Connect Customer Service department 24 hours a day, 7 days a week toll-free at 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m., or you may submit your request in writing by fax to 1-855-452-9133, or send by mail to:

CalOptima
Attn: OneCare Connect Customer Service
505 City Parkway West
Orange, CA 92868

You should contact OneCare Connect 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 (fast) review if you or your doctor believes 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 (fast) 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 Connect 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 Connect 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 the OneCare Connect Customer Service department toll-free at 1-855-705-8823, 24 hours a day, 7 days a week TDD/TTY users can call 1-800-735-2929. You may also visit our office Monday through Friday, from 8 a.m. to 5 p.m., or you may submit your appeal in writing by fax to 1-855-452-9133, or send by mail to:

CalOptima
Attn: Pharmacy Department
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 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 an independent review entity, hearings before an administrative law judge, review by the Medicare Appeals Council and judicial review. If you need assistance at any stage of the appeals process, you can contact the Cal MediConnect Ombudsman Program at 1-855-501-3077.

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.

To File a Complaint with Medicare

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

Complaints about your Medi-Cal Coverage

In addition to filing complaints about your Medicare coverage and/or services, you have the right to file complaints with CalOptima or with the Department of Social Services Hearing Office about your Medi-Cal coverage, In-Home Supportive Services (IHSS) and Multi-Purpose Senior Services Program (MSSP). To find out more about your Medi-Cal, IHSS and MSSP complaint and State Hearing rights, refer to your OneCare Connect Member Handbook. You may also contact the OneCare Connect Customer Service department toll-free at 1-855-705-8823, 24 hours a day, 7 days a week, for more information or assistance in filing a complaint or State hearing. TDD/TTY users can call 1-800-735-2929. You can also contact the Cal MediConnect Ombudsman Program at 1-855-501-3077 for assistance.

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

H8016_WEB18_001 Approved (11/01/2017)

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, co-pays, and restrictions may apply. For more information, call OneCare Connect Customer Service or read the OneCare Connect Member Handbook. Benefits and/or copayments may change on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. Other Pharmacies/Physicians/Providers are available in our network. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. OneCare Connect complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. You can get this information for free in other languages. Call toll-free 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. The call is free.

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