Policies & Procedures
Page last updated: October 01, 2023
© Copyright 2023 – Care N’ Care – All rights reserved. Y0107_24_114_M
An organization determination is a decision (approval or denial) Care N’ Care or its delegated entity makes regarding payment or provision of an item, service, or drug to which you believe you are entitled under Medicare Part C. An organization determination would involve these types of benefits:
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.
Asking for reimbursement also known as a Direct Member Reimbursement or DMR, is asking for an organization determination from us. To submit a reimbursement request please complete the Direct Member Reimbursement Request form (English) (Español). If you send in the form or paperwork that asks for reimbursement, we will check to see if the medical care you paid for is a covered service. We will also check to see if you followed all the rules for using your coverage for medical care.
We will say yes or no to your reimbursement 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
1603 Lyndon B. Johnson Freeway, Suite 300
Farmers Branch, TX 75234
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 decision notice, unless you can show good cause for delay. Please refer to Chapter 9, Section 4 of your Evidence of Coverage located on the 2024 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 pre-service or benefit or Part B drug 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 7 days for standard Part B drug requests, 30 days for standard pre-service or benefit requests and 60 days for payment requests.
The time to complete standard and fast pre-service or benefit 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. Part B drug timeframes cannot be extended.
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.
PLEASE NOTE: Individuals who represent you may either be appointed or authorized (both are referred to as “representatives”) to act on your behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process.
Any individual (e.g., relative, friend, advocate, or attorney) may act or be appointed as a representative. To have one of these individuals appointed, you must submit Form CMS-1696, Appointment of Representative (AOR), or an equivalent written notice.
A court acting in accordance with state or other applicable law which could include, court appointed guardian, individual with durable power of attorney, a health care proxy, a person designated under a health care consent statute, or an executer of an estate can act or be appointed as a representative. To have court appointed representation an AOR form is not required. However, court appointed individuals must produce the appropriate legal papers supporting his or her status under state law.
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 time-frame 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 Customer Experience Team 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
1603 Lyndon B. Johnson Freeway, Suite 300
Farmers Branch, TX 75234
Care N’ Care responds to all grievances in writing.
For more information, call the Care N’ Care Customer Experience Team from October 1 – March 31, 8 a.m. – 8 p.m., (CST) seven days a week or April 1 – September 30, 8 a.m. – 8 p.m. (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 Customer Experience Team 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 Customer Experience Team at the phone number listed above.
Complaints and disenrollment
If you have a complaint, you can file a grievance as noted above or complain to Medicare. You can also end your enrollment. To do that, refer to the information about disenrolllment on your rights page.
Policies & Procedures
© Copyright 2023 – Care N’ Care – All rights reserved. Y0107_24_114_M
Call 1-833-492-9866 (TTY:711)
Customer service representatives are available Monday – Friday 7 a.m. – 6 p.m. CST, to assist you.
Please visit athome.medline.com/cnc to place your order.
To download a copy of the OTC Catalog, go to:
llame al 1-833-492-9866 (TTY:711)
Los representantes de servicio al cliente están disponibles de lunes a viernes de 7 a.m. a 6 p.m. CST para ayudarlo.
Visite athome.medline.com/es/cnc para realizar su pedido.
Para descargar una copia del Catálogo OTC, vaya a:
PHI Form :: (English) (Español)
Automatic Bank Draft Form :: (English) (Español)
Direct Member Reimbursement Request :: (English) (Español)
Vision Out-of-Network Claim Form :: (English)
DentaQuest Dental Out-of-Network Claim Form :: (English)
Appointment of Representative :: (English) (English- Large Print) (Español) (Español – Letra Grande)
On June 22, 2023, Care N’ Care (CNC) Insurance Company, Inc. was notified that one of our vendors, TMG Health, Inc. (TMG), a third-party administrator that processes claims, discovered an information security incident related to personal information belonging to CNC members. This incident was part of a global cybersecurity breach involving the MOVEit Transfer Application used by thousands of organizations worldwide, including TMG, to transfer data.
Once the incident was discovered, TMG immediately initiated an investigation that confirmed an unauthorized party downloaded information belonging to CNC members between May 30, 2023, and June 2, 2023.
Affected CNC members were sent a written notification stating that an unauthorized party downloaded their personal information.
Steps that have been taken:
Safeguarding and securing member information is of the utmost importance to CNC. CNC is working closely with TMG to ensure their systems are updated to block these types of activities and prevent unauthorized disclosures from occurring in the future. TMG has notified law enforcement to mitigate this situation as best as possible.
To help protect affected members from potential identity theft, TMG offers one year of complimentary credit and identity theft monitoring through the data breach mitigation vendor IDX. IDX has a call center team specializing in identity protection to address members’ questions. The center can be reached at 1-888-727-2311 Monday through Friday from 9 a.m. – 9 p.m. ET or through their response website. At this time, we have no reason to believe that anyone has misused CNC member information.
For accommodations of persons with special needs call1-877-374-7993 (TTY 711)
Care N’ Community has partnered with several Tarrant County YMCAs to jointly offer a host of weekly programs designed to increase independence, reduce isolation and encourage healthy living of local-area seniors.
The programs – open to all seniors in the area – vary greatly from week to week, depending on the needs and wants of the participants. Some programs stress physical activity, such as water aerobics; some are strictly social, such as adult coloring classes or organized breakfast and lunch groups; and some are educational, such as safety tips from local police or healthcare tips from local doctors and nurses.
Currently, Care N’ Community offers programming at the following YMCA locations:
Call one of our Local Medicare Guides today at 1-800-994-0217 (TTY 711).
They are available 8am to 8pm, CST seven days a week from October 1 – March 31, or 8am to 8pm, CST, Monday through Friday, April 1 – September 30 to help with any questions you may have.
Email: yourteam@cnchealthplan.com
Call: 1-877-374-7993 (TTY 711)
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.
Mail: Care N’ Care Insurance Company, Inc.
Attn: Customer Experience Team
1603 Lyndon B. Johnson Freeway, Suite 300
Farmers Branch, TX 75234
By Email: providerconcierge@cnchealthplan.com
By Phone: 817-687-4004
Members automatically receive a copy mailed to your home. If you would prefer to receive electronically and save paper – Sign-up today! Just complete the form below and we will add you to our eNewsletter that is delivered by email, every quarter. It is the same newsletter that is mailed to members homes.
It’s your choice! Email, Text Messages, U.S. Mail or some of each?
In an effort to reduce paper and deliver communication to our members, we offer plan material and communications electronically to our members. If you choose, we will securely send plan materials to your email address instead of your mailbox. It’s easy and will help us reduce our carbon footprint by limiting the materials we print.
The email electronic option does not apply to all mailings sent to you from Care N’ Care. To protect your personal health information, we will continue to send personal health information to you by U.S. Postal Service.
Make your choice by completing the form below or contacting your Customer Experience Team to assist you.
Pending Approval
Thank you for your interest in becoming part of the Care N’ Care provider network. Please complete the online contract request form. Provider selection is based on numerous factors.
Need a copy of your plan material? Would you like an electronic copy emailed to you or a printed copy mailed to your home? Complete the form below to let us know and we will make sure you receive as requested!
Members may pay their monthly premium online using PayPal. PayPal allows you to make payments using a variety of methods including:
Lost or damaged Care N’ Care member identification card? Complete the online form below to request a replacement card.
To make a change to your primary care physician on your ID card, please contact your Customer Experience Team at 1-877-374-7993 (TTY 711) or email yourteam@cnchealthplan.com
Play a role in the evolution of our growing senior communities while you expand your social circle, refresh those workplace skills you spent so long developing, or just enjoy the satisfaction that comes with being a community volunteer. Volunteers can be of any age! There are a variety of opportunities for volunteers seeking tasks that are detail-oriented, focused, offer flexibility, and critical to the community.
Our mission that Care N’ Community, will work hand-in-hand with the areas in which we serve to create an intergenerational support system that fosters and promotes well-being, empowerment and independence for safe and vibrant aging.
Our vision is to engage the community in such a way that we all prosper and do not age alone.
Care N’ Community is looking for strategic partnerships with local businesses and organizations who also have a vested interest in the success of the aging community as well. Care N’ Care is focusing on the link between strong communities, senior involvement, population health and encouraging our communities to become more involved and innovative in their efforts to work in concert. These partnerships offer educational, social and volunteer opportunities for everyone.
Transportation: Every once in a while seniors need a little assistance getting to medical appointments, social or cultural events, worship services, hairdresser or barbers, grocery stores and running errands. There are organizations in our community to assist seniors with these needs. Many seniors need assistance with errands such as grocery shopping, clothing and gift shopping, or picking up prescriptions.
Social Programs: Staying active in retirement is easy. With the senior social programs, there is always something fun and exciting going on in the area. Help host an outing or just attend. Active seniors will have the opportunity to attend outings such as going to lunch, attending fitness classes, cultural events, and entertainment or going to shopping destinations. There’s no one-size-fits all, there are a variety of activities available. Once a week, once a month, first Tuesday of the month whichever the case may be, we love social and like-minded gatherings. From a men’s breakfast group, to lunch bunches, book clubs, coffee groups, happy hours and small group studies there is an opportunity for everyone. Making new friends and escaping the isolation from home is always a treat.
Convenience Task & Handyman Services: Assistance with light yard work, minor household organization and cleaning, pet care, plant care, minor household chores such as hard to reach light bulbs, hang pictures, check smoke alarms, moving outdoor furniture, and simple repairs. Neighbors helping neighbors at home. For home repairs that require a little more work or a skilled tradesman, Care N’ Community can refer seniors to organizations that have pre-screened vendors.
Contact:
Kelli Blackwelder, Community Engagement Manager
Phone: 1-844-656-7667
Email: social@carencommunity.com
Staying active in retirement is easy. With the senior social programs, there is always something fun and exciting going on in the area. Active seniors will have the opportunity to attend outings such as going to lunch, attending fitness classes, cultural events, and entertainment or going to shopping destinations. There’s no one-size-fits all, there are a variety of activities available. Once a week, once a month, first Tuesday of the month whichever the case may be, we love social and like-minded gatherings. From a men’s breakfast group, to lunch bunches, book clubs, coffee groups, happy hours and small group studies there is an opportunity for everyone. Making new friends and escaping the isolation from home is always a treat.
Contact:
Kelli Blackwelder, Community Engagement Manager
Phone: 1-844-656-7667
Email: social@carencommunity.com