An organization determination is a decision (approval or denial) Care N’ Care makes regarding payment or benefits to which you believe you are entitled under Medicare Part C. An organization determination would involve these types of benefits:

• Out of the area renal dialysis services
• Payment for any other health services furnished by a provider
• Discontinuation of a service when you believe that continuation of the service is medically necessary

How to request an organization determination

You, your appointed representative or your physician may request an organization determination. You or your appointed representatives may 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 for an organization determination, call 1-877-374-7993 ( TTY: 711), fax to 817-810-5214 or mail to the address below:

Care N’ Care
Attn: Organization Determination
1701 River Run, Suite 402
Fort Worth, TX 76107

Part C Appeals

If you disagree with the outcome of an organization determination, you, your Appointed Representative, or your prescribing physician may file an appeal called a plan “reconsideration”. You must ask for it within 60 days from the date of our denial notice, unless you can show good cause for delay. Please refer to your Evidence of Coverage located on the 2019 Plan Documents or 2020 Plan Documents page that discusses the five (5) levels of appeal. When our plan is reviewing your appeal, we take another careful look at all of the information about your initial organization determination request. You also have the right to give us new information supporting your appeal request. We check to see if we were being fair and following all the rules when we said no to your initial request. We may contact you or your doctor or other provider to get more information.

How long does it take for a Part C appeal decision?
You, your Appointed Pre-service Representative, or your treating physician can ask for a standard or fast appeal.

You will get a fast decision if we determine or your physician tells us, that your life or health may be at risk by waiting for a standard decision. If we are using the fast deadlines, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

If we are using the standard deadlines, your appeal must be submitted in writing. We must give you our answer within 30 days for standard pre-service requests and 60 days for payment requests.

The time to complete standard service and fast appeals may be extended by up to 14 days if, for example, we need more information to make a decision about the case, and the extension is in your best interest.

How to request a Part C appeal

You, your Appointed Representative, or your treating physician can submit a Part C appeal by fax or mail or for a fast appeal, by phone.

• FAX: 817-810-5214 to Attn: Part C Appeals & Grievances
• MAIL: Care N’ Care
  Attn: Part C Appeals & Grievances
  1701 River Run, Suite 402
  Fort Worth, TX 76107
• PHONE: In the case of a fast appeal 877-374-7993 (TTY 711) to speak to your Healthcare Concierge.

PLEASE NOTE: Those you wish to appoint to represent you during your appeal must first sign an Appointment of Representative form. You may submit the signed form to Care N’ Care either by fax or mail.

Part C Grievances
A grievance is any dispute other than one that involves an organization determination that expresses dissatisfaction with the operations, activities or behavior of Care N’ Care or one of our providers. This includes problems related to quality of care, waiting times, and the customer service you receive.

You, or your Appointed Representative can ask for a grievance. A grievance must be filed within 60 days from the date of the event that led to the complaint.

Expedited or fast grievances will be responded to within 24 hours if the grievance is related to the plan’s refusal to make a fast organization determination or reconsideration and you haven’t received the medical care yet.

We will address other grievance requests within the standard timeframe of 30 days following the receipt of your complaint. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days to answer your complaint

How to file a Part C Grievance

By Phone: Call your Healthcare Concierge at 1-877-374-7993 (TTY 711)

By FAX: 817-810-5214 to Attn: Part C Appeals and Grievances

By MAIL: Care N’ Care

Attn: Part C Appeals & Grievances
1701 River Run, Suite 402
Fort Worth, TX 76107

Care N’ Care responds to all grievances in writing.

For more information, call the Care N’ Care Healthcare Concierge from October 1 – March 31, 8 am – 8 pm, (CST) seven days a week or April 1 – September 30, 8 am – 8 pm (CST), Monday through Friday.

Status requests

For questions regarding the process or status of organization determinations, appeals, and/or grievances you, your Appointed Representative, or your treating physician should call your Healthcare Concierge at 1-877-374-7993 (TTY: 711).

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 your Healthcare Concierge at the phone number listed above.

Complaints and disenrollment

If you have a complaint, you can complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrolllment on your rights page.