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Medicare Member Services

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Member Services

How to Request an Organization Determination

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 three days after we receive your request. However, we can take up to 14 more calendar days if we need information (such as medical records) that may benefit you for certain issues.

If your health requires it, ask us to give you a "fast decision". A fast decision means we will answer within 24 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing for certain issues.

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: 800-508-6157 - Calls to this number are free. Hours of operation: 8:00 a.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: 866-706-6929
  • Write:
    • ConnectiCare
      Attn: Medicare Utilization Management
      P.O. Box 4050
      Farmington, CT 06034-4050

 

Prescription Drug Coverage Determinations

Grievances & Appeals

Understanding Grievances (Complaints)

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: 800-224-2273 - Calls to this number are free. From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday. 
  • 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. From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday. 
  • Fax: 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 at 800-224-2273 (TTY: 711). From Oct. 1 to March 31, you can call from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call from 8 a.m. to 8 p.m., Monday through Friday to request a report, check status, or process questions.

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

Understanding Medical Appeals (Reconsiderations)

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: 800-224-2273 (TTY: 711). From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday. 
  • Fax: 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 at 800-224-2273 (TTY: 711). From Oct. 1 to March 31, you can call from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call from 8 a.m. to 8 p.m., Monday through Friday to request a report, check status, or process questions.

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

Prescription Drug Grievances & Appeals

Appoint a Representative

How to 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

How to Avoid Membership Termination From the Plan.

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 8 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. 

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Important Medicare Forms

Find enrollment applications, formularies, plan documents and more.

We're Here for You

If not currently enrolled call 877-224-8221 (TTY: 711)

From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Friday. 

Medicare members call 800-224-2273 (TTY: 711)

From Oct. 1 to March 31, you can call us from 8 a.m. to 8 p.m., seven days a week. From April 1 to Sept. 30, you can call us from 8 a.m. to 8 p.m., Monday through Saturday. 

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Last Update: 10/01/2024

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