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Learn how to request an organization determination (the process to determine if an item or medical service is covered).

Understanding Coverage Decisions (Organization Determinations)

You have the right to request a coverage decision if you want us to provide or pay for an item or service that you believe should be covered. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. 

To request a coverage decision, start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. 

When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

If your health requires it, ask us to give you a "fast decision". A fast decision means we will answer within 72 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.

To get a fast decision, you must meet two requirements: 

  • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast decision. If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast decision. 

COVERAGE DECISIONS FOR MEDICAL CARE

Call

1-800-508-6157
Calls to this number are free.
Hours of operation: 8:00a.m. - 5:00 p.m., Monday through Friday.

TTY

711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
Hours of operation: 8:00 a.m. - 5:00 p.m., Monday through Friday.

Fax

1-866-706-6929

Write

ConnectiCare
Attn: Medicare Utilization Management
P.O. Box 4050
Farmington, CT 06034-4050

Grievances & appeals

You have the right to file a grievance (complaint) with us if you have any type of problem with us or one of our network providers, including a complaint about the quality of your care.  You also have the right to file a grievance with the Beneficiary and Family Centered Care Quality Improvement Organization (Also known as BFCC-QIO) for the State of Connecticut. Please refer to the Evidence of Coverage (EOC) for the BFCC-QIO contact information.

Send the written request for a standard or expedited grievance no later than 60 calendar days after the grievance incident.  You must include the following:

  • First name, last name, address, phone number, date of birth, and ConnectiCare ID number.

  • Reason why you are filing a grievance.

You should send any supporting documentation that you believe may help your case, including medical records, with your grievance. 

Grievances

Call
1-800-224-2273
Calls to this number are free.
Hours of operation: 8:00 a.m. - 8:00 p.m., seven days a week.

TTY
711
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Calls to this number are free.
Hours of operation: 8:00 a.m. - 8:00 p.m., seven days a week.

Fax
1-800-867-6674

Write
ConnectiCare
Medicare Appeals and Grievances
P.O. Box 4010
Farmington, CT 06034
Attention: Medicare Appeals Department

How can I obtain information about an aggregate number of grievances, appeals, and exceptions filed with ConnectiCare?

If you want information about the aggregate number of grievances, appeals, and exceptions filed with ConnectiCare, you may contact member services to request a report. 

You can submit a complaint directly to Medicare. To submit an online complaint to Medicare, go to Medicare Complaint Form.

You have the right to file an appeal if we deny coverage for an item or service. An appeal is a formal way of asking us to review and change an organization determination we have made.  You may ask us for an expedited (fast) appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision.

File the verbal or written request for a standard or expedited appeal within 60 calendar days from the date of the notice of the organization determination (except when the filing time frame is extended).  You must include the following:

  • First name, last name, address, phone number, date of birth, and ConnectiCare ID number.

  • The name of the item or service you want your plan to cover.

  • Reason why you are appealing.

You should send any supporting documentation that you believe may help your case, including medical records, with your appeal request.

Appeals for medical care

Call
1-800-224-2273 (TTY: 711) between 8:00 a.m. and 8:00 p.m. seven days a week

Fax
1-800-867-6674

Write
ConnectiCare
Medicare Appeals and Grievances
P.O. Box 4010
Farmington, CT  06034
Attention: Medicare Appeals Department

In person
ConnectiCare
175 Scott Swamp Road, Farmington, CT 06034

How can I obtain information about an aggregate number of grievances, appeals, and exceptions filed with ConnectiCare?

If you want information about the aggregate number of grievances, appeals, and exceptions filed with ConnectiCare, you may contact member services to request a report. 

You can submit a complaint directly to Medicare. To submit an online complaint to Medicare, go to Medicare Complaint Form.

Appoint a representative

If you want someone to act on your behalf then you and that person must sign a statement that gives that person legal permission to act as your appointed representative.

Individuals who represent enrollees may either be appointed or authorized. An enrollee may appoint any individual (such as a relative, friend, advocate, an attorney, or any physician) to act as his or her representative in filing a grievance, requesting an organization determination, or in dealing with any of the levels of the appeal process. Also, a representative (surrogate) may be authorized by a court or act in accordance with State law to file an appeal for an enrollee. A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney, or a health care proxy, or a person designated under a health care consent statute. 

To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete a Appointment of Representative Form (CMS-1696 Form).  

Due in part to the incapacitated or legally incompetent status of an enrollee, a surrogate is not required to produce a representative form. Instead, he or she must produce other appropriate legal papers supporting his or her status as the enrollee's authorized representative.

Either the signed representative form for a representative appointed by an enrollee, or other appropriate legal papers supporting an authorized representative's status, must be included with each request for a grievance, an organization determination, or an appeal. Regarding a representative appointed by an enrollee, unless revoked, an appointment is considered valid for one year from the date that the appointment is signed by both the member and the representative. Also, the representation is valid for the duration of a grievance, a request for organization determination, or an appeal. 

A photocopy of the signed representative form must be submitted with future grievances, request for organization determinations, or appeals on behalf of the enrollee in order to continue representation. However, the photocopied form is only good for one year after the date of the enrollee's signature. Any grievance, request for organization determination, or appeal received with a photocopied representative form that is more than one year old is invalid to appoint that person as a representative and a new form must be executed by the enrollee.

Instructions on how to appoint a Representative

Please note that only sections I, II, and III of the form apply to the Medicare Advantage program. 

  • Section I: Appointment of Representative section
     The name of the representative is required. In addition, the Medicare Beneficiary must sign and date the form, and complete their address.

  • Section II: Acceptance of Appointment section
     The representative should enter their name in the 1st paragraph, identify their relationship to the beneficiary, sign and date the form, and complete the address / telephone section.

  • Section III: Waiver of Fee for Representation Instructions
     This section must be completed if the representative is required to, or chooses to waive their fee for representation.

  • Section IV: Waiver of Payment for Items or Services at Issue
     Does not apply to the Medicare Advantage Program.

Potential reasons for plan/policy termination

You have some responsibilities as a member of ConnectiCare. Discover how to avoid membership termination from the Plan.

In all instances when your membership ends, you will be given proper notice and an opportunity to challenge the decision related to your disenrollment. Your membership in the Plan may end if: 

  • You attest to permanently moving outside of our service area or you move out of our service area for more than six months.

  • You withhold information about other insurance you have that provides prescription coverage or if you intentionally give us incorrect information when you are enrolling in our Plan and that information affects your eligibility for our Plan.

  • You continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our Plan.

  • You do not pay the Plan premiums for up to three months. If you need extra help to pay for the costs of your prescription drugs and premiums, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 711, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or Your State Medicaid Office.

If you disenroll from our plan, please note the following: 

  • If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins).
  • You have the right to make a complaint if we end your membership in our plan.

  • If we end your membership in our plan, we must tell you our reasons in writing for ending your membership.

  • We must also explain how you can make a complaint about our decision to end your membership.

For more details about disenrollment, please refer to the section "Ending your membership in the plan" in your Evidence of Coverage (EOC) document. 

 

Contract Termination

All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. 

Special needs plan

Your ConnectiCare Choice Dual (HMO D-SNP) plan comes with additional benefits to help you get the care you need. Below are the details you need to know about each benefit:

 

Over-the-counter (OTC) benefit card

Before your plan’s effective date, we will mail you an over-the counter card. You can use this card to buy eligible non-prescription drugs and health items:

  • At participating retailers, like CVS, Rite Aid, Walgreens, and Walmart; or
  • Over the phone or online from NationsOTC, and have them delivered to your home.

Eligible items include:

  • Antacids

  • Adult aspirin and sinus medicines

  • Allergy and sinus medicines

  • Cold and flu medicines
  • Laxatives

  • Denture or dental care items

  • Ear drops and eye wash

  • Vitamins and minerals

Go to www.otcnetwork.com to find out what items you can buy with your OTC card, where participating retailers are located, and what your card balance is. You can also call 1-866-236-3764 to check the card balance.

For home delivery, get information in this NationsOTC brochure, visit the website, or call 877-388-3314 (TTY: 711).

Things to keep in mind about the OTC card:

  • Use the card only for yourself and your OTC drugs and health items. Keep it in a safe place.

  • Every month, we will add a $50 maximum allowance to your card as long as you’re actively enrolled in our special needs plan. This amount does not roll-over and will expire at the end of each month.

 

Non-emergency transportation

Your plan includes non-emergency transportation. It covers up to 24 one-way trips per person to approved locations and appointments like:

  • Doctors and specialists

  • Dentists

  • Pharmacies
  • Urgent care

  • Physical, occupational or speech therapy

Call the number below between 8 a.m. and 8 p.m. Monday through Friday to schedule, change or cancel rides:

1-800-224-2273 (TTY: 711)

If you need to cancel or change your ride, please call as soon as possible because if you miss a scheduled transportation pickup, it may still count as one of your 24 eligible trips.

Vision allowance

Your plan includes a $300 allowance every two years for routine eyewear like:

  • Eyeglasses (frame and lenses) or

  • Eyeglass lenses only or

  • Eyeglass frames only or

  • Contact lenses

This vision allowance only covers routine eyewear dispensed by EyeMed® Insight network providers. Please visit the EyeMed website to find a participating provider in the EyeMed® Insight network, click “Find a Provider” and in the drop down choose “Insight Network.” or call 1-833-337-3134 (TTY: 711) to find a participating provider.

Please note, the $300 allowance does not count towards your maximum out-of-pocket.”

 

Nurse hotline

A registered nurse is on call 24/7 if you have non-emergency health and medical questions. Your call is confidential. There is no cost to you to call the nurse hotline:

1-877-489-0963

Remember, if you have an emergency, call 911 or use your local emergency number.

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Last update 07/29/2020

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Medicare members call 1-800-224-2273
If not currently enrolled call 1-877-224-8221
(TTY: 711)

8 a.m. to 8 p.m., seven days a week