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:

• Payment of temporary out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
• Payment for any other health services furnished by a provider
• Refusal or premature discontinuation of a previously authorized ongoing course of treatment
• Failure of Care N’ Care to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provider timely notice of an adverse determination, such that a delay would adversely affect your health

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. 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:

• If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven’t paid for the services, we will send the payment directly to the provider. When we send the payment, it’s the same as saying yes to your request for an organization determination.)
• If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the services and the reasons why in detail. (When we turn down your request for payment, it’s the same as saying no to your request for an organization determination.)

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 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.

• FAX: 817-810-5214 to Attn: Part C Appeals & Grievances
• MAIL: Care N’ Care
  Attn: Part C Appeals & Grievances
  1603 Lyndon B. Johnson Freeway, Suite 300
  Farmers Branch, TX 75234
• PHONE: In the case of a fast appeal 877-374-7993 (TTY 711) to speak to your Customer Experience Team.

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