Coverage Determinations

Coverage Determinations, Formulary Exception Requests, Appeals, and Grievances Processes

We encourage you to let us know right away if you have questions, concerns, or problems related to your covered services or the care you receive. Please call your Partnership Team or call Member Services at 1-866-992-6600 (TTY number is 1-414-385-6626).

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your medical care as a plan participant. The Medicare and Medicaid programs have helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled from Community Care’s Partnership Program or penalized in any way if you make a complaint.

Grievances and appeals are the two different types of complaints you can make. The process you can use varies slightly depending on whether it is a Medicaid service or a Medicare benefit. If you are not sure how to proceed, your Team can help you determine how to proceed.

Click on one of the following links to learn more:

Coverage Determinations
Formulary Exception Requests
Appeals
Grievances
Additional Resources

You can request a coverage determination anytime you feel you need a service or benefit covered by Community Care. Please call your Partnership Team to request a coverage determination. You can also submit a written request to:

Community Care
Attn: Coverage Determination Request
1555 S. Layton Blvd.
Milwaukee, WI 53215

Toll Free: 1-866-992-6600
TTY: 1-414-385-6626

If your coverage determination involves your prescription drug coverage, Community Care will treat it as a Formulary Exception request.

TOP

Formulary Exception Requests

You can request a Formulary Exception if you want to receive a prescription drug that is not in Community Care’s Formulary or if it is on a different tier of the formulary (e.g., if you want a prescription drug where Community Care is providing a generic alternative).

You can request a drug coverage determination verbally to your Partnership Team or you make a written request. To help you provide necessary information, you can complete Medicare Part D Coverage Determination Request Form and mail it to Community Care.

Instructions for the Medicare Part D Coverage Determination Request Form
Use of this form is optional. The format and content of this form may be changed by any person or entity that uses it. If this form is used, Community Care may require additional information or documentation to support your request.

You can submit this form to Community Care by giving it to your Partnership Team or by mailing it to...

Community Care
Attn: Formulary Exceptions Request
1555 S. Layton Blvd.
Milwaukee, WI 53215

Toll Free: 1-866-992-6600
TTY: 1-414-385-6626

TOP

An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you or what we will pay for a service or benefit. For example, if we refuse to cover or pay for services you think we should cover, you can file an appeal. If Community Care or one of our plan providers refuses to give you a service you think should be covered, you can file an appeal. If Community Care or one of our plan providers reduces or cuts back on services or benefits you have been receiving, you can file an appeal. If you think we are stopping your coverage of a service or benefit too soon, you can file an appeal.

Your appeal rights will depend on whether the service in question would have been a Medicare service or a Medicaid service. Community Care will explain your appeal rights in the appeal notification letter when we make a coverage determination or when we deny a formulary exception request.

Appeals of Medicare Benefits
For appeals of Medicare benefits, you must appeal to the Community Care Appeal Committee toll free at 1-866-992-6600 (TTY number is 1-414-385-6626). You can also send an appeal letter to:

Community Care
Appeal Committee
1555 S. Layton Blvd.
Milwaukee, WI 53215

If Community Care then wholly or partially denies your appealed service, we will automatically request a review of our decision with Medicare’s independent review organization.

Appeals of Medicaid Services
For appeals of Medicaid or Medicaid-waiver services, you must follow the Medicaid appeal process. This means that you can appeal to Community Care, the Wisconsin Department of Health and Family Services (DHFS), or the Wisconsin Division of Hearings and Appeals (DHA).

Community Care: You can appeal this decision to the Community Care Appeal Committee toll free at 1-866-992-6600 (TTY number is 1-414-385-6626). You can also send an appeal letter to:

Community Care
Appeal Committee
1555 S. Layton Blvd.
Milwaukee, WI 53215

DHFS: You can appeal to the Managed Care Ombuds by contacting them at:

EDS
Managed Care Ombuds
P.O. Box 6470
Madison, WI 53716-0470
Toll Free Number: 1-800-760-0001

DHA: You can request a fair hearing with the DHA by sending your request in writing to:

Wisconsin Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707-7875
Phone: 1-608-266-3096
Fax: 1-608-264-9885

TOP

Grievances

A “grievance” is the type of complaint you make if you have any problem with Community Care or one of our plan providers that is not an appeal. For example, you would file a grievance if you have a problem with things such as the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor’s office.

Grievances help Community Care to improve the services we provide to you and all of our participants. We encourage you to work with us to resolve your concerns. Whenever possible, start by talking with your Partnership Team about your problem. If you are still not satisfied after talking with your Team, you may submit a grievance by calling or writing to Community Care at:

Community Care
Quality Improvement Department
1555 S. Layton Blvd.
Milwaukee, WI 53215

Toll Free: 1-866-992-6600
TTY: 1-414-385-6626

If you submit your grievance to Community Care, please give us complete information so we can resolve your concern in a timely manner.

TOP

Managed Care Ombuds
For help in filing an appeal, please call the Community Care Appeal Committee toll free at 1-866-992-6600 (TTY: 1-414-385-6626), or you can contact the Managed Care Ombuds at: