Your Rights: Coverage Determinations, Organization Determinations, Appeals and Grievances.

Care N’ Care wants to provide you with thorough coverage and satisfactory service in all aspects of your medical and prescription drug coverage. Therefore, we have outlined various procedures to help you make different kinds of requests. As a member of Care N’ Care, you have the right to submit a coverage determination, organization determination, appeal or grievance as needed.

You can learn more about how and why to submit coverage determinations, organization determinations, appeals and grievances by viewing the Care N' Care Evidence of Coverage (Sections # & #, pages ##) or by clicking on the individual topics below

What is a coverage determination?
A coverage determination is a decision for a Part D drug (approval or denial) made by Care N’ Care regarding payment or benefits to which you believe you are entitled. This includes decisions with respect to one of the following issues:

           Whether to provide or pay for a part D drug
 
           Tiering exceptions
 
           Formulary exceptions
 
           Cost sharing for a drug
 
           Prior authorization requirements or step therapy restrictions

Your doctor can provide a statement to support these types of requests.

How to request a coverage determination

For Part D Drugs, Care N’ Care delegates responsibility for making coverage determinations to its Pharmacy Benefits Manager (PBM), RxAmerica.
As a member of Care N’ Care, you, your appointed representative or your prescribing physician may request a coverage determination.

Member or appointed representative requests
Care N’ Care members or their appointed representatives can call, fax or mail in a request for a coverage determination. However, the preferred method is to have your prescribing physician call RxAmerica with a supporting statement of your request. It is recommended to have your doctor provide a supporting statement for your request as indicated on the form below.

Appointing a representative
An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Those not authorized under state law to act for you will need to sign an Appointment of Representative form and mail it to:
Care N’ Care
Attn: Customer Service
1701 River Run, Suite 201
Fort Worth, TX, 76107

An attorney can also ask for a coverage determination on your behalf.

To file your request, please use the following form and contact information:

Form: Request for Medicare Prescription Drug Coverage Determination
Phone: 800-260-1327
TTY: 866-547-0773
Fax: <insert #>
Mail:
RxAmerica Medicare
Attn: Coverage Determinations
P.O. Box 22690
Salt Lake City, UT 84122-0690

Physician Requests
Prescribing physicians can file a coverage determination on behalf of Care N’ Care members via phone or fax. The preferred method of request is for a prescribing physician to call RxAmerica directly to ensure the receipt and expedient processing of his or her supporting statement.

For a prescribing physician to file a coverage determination request, he or she should use the following form and contact information:

Form: Coverage Determination Request (for physician use)
Phone: 800-260-1327
TTY: 866-547-0773
Fax: <insert #>
Mail:
RxAmerica Medicare
Attn: Coverage Determinations
P.O. Box 22690
Salt Lake City, UT 84122-0690

What is an Organization Determination?
An Organization Determination is a decision (approval or denial) made by Care N’ Care regarding payment or benefits to which you believe you are entitled under Medicare Part C. Following are examples of what type of benefit an organization determination would involve:

           Out of the area renal dialysis services

           Payment for any other health services furnished by a provider

           Discontinuation of a service if the enrollee believes that
                 continuation of the services is medically necessary

How to request an Organization Determination
As a member of Care N’ Care, you, your appointed representative or your physician may request an organization determination.

Member, physician, or appointed representative requests
Care N’ Care members or their appointed representatives can call, fax or mail in a request for an organization determination. However, the preferred method is to have your prescribing physician call Care N’ Care with a supporting statement for your request. It is recommended but not required to have your doctor provide a supporting statement for your request.

To file your request, please use the following contact information:

Phone: 817-529-5267
TTY: 817-529-5268
Fax: 817-810-5214
Mail:
Care N’ Care
Attn: Appeals and Grievances
1701 River Run, Suite 201
Fort Worth, TX 76107

What is an appeal?
If you are unsatisfied with the outcome of a coverage determination or organization determination request, you can ask for an appeal. An appeal is a procedure whereby Care N’ Care or RxAmerica for Part D drugs will review your unfavorable coverage determination or organization determination.

The first level of appeal for a Part D drug is called a redetermination; the first level of appeal for a Part C is called reconsideration. You may file for a Part D redetermination or Part C reconsideration if you want Care N’ Care to reconsider a decision regarding payment or benefits to which you believe you are entitled. There are five levels of appeals.

How to request an appeal
As a Care N’ Care member, you, your appointed representative or your prescribing physician may file for an appeal of a coverage determination or an organization determination.

Member or physician Appeal (redetermination for Part D or reconsideration for Part C) requests
Appeals must be filed within 60 calendar days of the date included on the notice of the Care N’ Care coverage determination or organization determination. More time may be granted depending on circumstances.

To file a standard redetermination (Appeal) request, please use the following contact information:

Phone: 800-260-1327
Fax: <insert #>
Mail:
RxAmerica Medicare
Attn: Medicare Casework Department
P.O. Box 22524
Salt Lake City, UT 84122-0524

To file a standard reconsideration (Appeal) request for Part C, please use the following contact information:

Phone: 817-529-5267
Fax: 817-810-5214
Mail:
Care N’ Care
Attn: Appeals and Grievances
1701 River Run, Suite 201
Fort Worth, TX 76107

What is a grievance?
A grievance is any dispute (other than one that involves a coverage determination or an organization determination that expresses dissatisfaction with the operations, activities or behavior of Care N’ Care or one of our providers. For example, grievance can involve a problem with waiting times at you physician’s office, behavior of a network pharmacist, ability to get the information you need or the condition of a network pharmacy or physicians office.

How to file a Grievance If you would like to file a verbal Grievance, you can call Care N’ Care Customer Service 8:00 a.m.–8:00 p.m., seven days a week, at the number below.

Phone: 817-529-5267
TTY: 817-529-5268

If you request a written response to your phone complaint, we will respond to you in writing. If you would like to file a Grievance in writing, please send your Grievance to the address below.

Send Written Grievances to:
Fax: 817-810-5214
Mail:
Care N’ Care
Attn: Appeals and Grievances
1701 River Run, Suite 201
Fort Worth, TX 76107

For more information, you can call the Care N’ Care Customer Service department from 8 a.m.–8 p.m., seven days a week, at the following toll-free numbers:

Phone: 877-374-7993
TTY: 877-374-7994

Status of a request: Member or appointed representative inquiries
For questions regarding the process or status of a coverage determination, organization determination, redetermination or reconsiderations request, you or your appointed representative should call Care N’ Care at the following toll-free numbers:

Coverage Determinations & Redeterminations

Phone: 800-260-1327
TTY: 866-547-0773
Fax: <#>

Organization Determinations & Reconsiderations

Phone: 817-529-5267
TTY: 817-529-5268
Fax: 817-810-5214

If your first appeal is denied or if you disagree with any part of our Appeal (redetermination, or reconsideration) decision, you can request further appeal levels. Complete details on all appeal levels can be found in the Care N’ Care Evidence of Coverage.

Status of a request: Physician inquiries
Your physician can inquire about the process or status of a coverage determination, organization determination or appeal request by calling Care N’ Care at the following toll-free numbers:

Coverage Determinations & Redeterminations

Phone: 800-260-1327
TTY: 866-547-0773
Fax: <#>

Organization Determinations & Reconsiderations

Phone: 877-374-7993
TTY: 877-374-7994
Fax: 877-810-5214

Grievances, appeals and exceptions data
Care N’ Care tracks and maintains records about the receipt and handling of grievances, appeals and exceptions. We will also disclose grievances, appeals and exceptions data to you upon request. To obtain this data, please call Care N’ Care Customer Service at 817-529-5267, TTY users should call 817-529-5268 from 8:00a.m. to 8:00p.m. seven days per week.

Care N’ Care materials are available in alternative formats, please contact customer services for details.