Policies for Member Privacy, Rights, Appeals, Grievances and Formulary Exceptions

It is very important to us that you have easy access to and understand the policies that have been put in place that will ensure you get the proper care and respect you deserve.

On this page you will find the following information:

Member Privacy Policy – applies to all plans
Member Rights and Responsibilities – applies to all plans
Appeals and Grievances Policies, Procedures and Forms – applies to all plans
Prescription Drug Policies and Forms for requesting Formulary Exceptions and Coverage Determinations – applies only to our Medicare Advantage Plans with Pharmacy and Medicare Advantage Special Needs Plan

Member Privacy

Community Health Plan is required by a federal law called the Health Information Portability and Accountability Act of 1996 (HIPPA) to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to your protected health information. Protected health information means any information, including information this is identifiable to you as your personal information, including information on your health care and treatment, your name, age, address and social security.

Notice of Privacy Practices.

Member Rights & Responsibilities

The purpose of this policy is to set forth the rights of Community HealthFirst's Medicare Advantage members in accordance with all applicable State and Federal laws, specifically 42 CFR §438.100 and including Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 484; the Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91; the Rehabilitation Act of 1973; and Titles II and III of the Americans with Disabilities Act and other laws regarding privacy and confidentiality.

Member Rights and Responsibilities Policy Statement

Your rights and responsibilities upon disenrollment

You must continue to use network pharmacies until you are disenrolled from our plan.
You may only disenroll or switch prescription drug plans under certain circumstances.
You have the right to make a complaint if we ask you to leave our plan.

Our rights and responsibilities upon your disenrollment
We will let you know, in writing, the date your coverage ends. We have the right to disenroll you for the following reasons:

You are no longer eligible for Medicare prescription drug coverage.
If we are no longer contracting with Medicare or we leave your service area.
When you move out of our service area.
You materially misrepresent third party reimbursement.
You fail to pay your plan premium.
You provide fraudulent information when you enroll or abuse the terms of your enrollment.

Appeals & Grievances

We take your concerns seriously and consider them opportunities to improve care and service to our enrollees. Following is an overview of the Community HealthFirst Appeals and Grievance Policies.

Appeals & Grievance policy booklet.

Appeals
An appeal is the type of complaint you make when you want us to reconsider a decision we have made about what benefits are covered under your plan or what we will pay. For example, you might appeal if:

you feel we have not paid for a particular medical procedure or other service you think should be covered;
your plan has coverage for prescription drugs (Part D) and we will not approve payment for care or prescription drug you believe should be covered (please see the Coverage Determination section below on this page);
your plan has coverage for prescription drugs (Part D) and we are stopping payment for care or Part D benefit you need (please see the Coverage Determination section below on this page).

If you wish to file an Appeal, it must be done within 60 days of the notice of denial date. There are 2 kinds of appeals: standard and expedited (rush).

A standard appeal request must be in writing and sent to:

Community Health Plan
Attn: Community HealthFirst Appeals
720 Olive Way, Suite 300
Seattle, WA 98101

An expedited appeal can be submitted in writing to the address above, or verbally by calling 1-800-942-0247 (TTY/TDD hearing imparied 866-816-2479), 8 a.m. to 8 p.m., 7 days a week. You should file an expedited appeal if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.

You can also fax your appeal request to: 206-613-8983 or deliver it in person to the address listed above.

If you wish to file an Appeal in writing, click here for our Appeal Form. Be sure you clearly indicate which type of appeal you are making on the form. If you wish to have someone to act on your behalf, you must fill out our Appointment of Representative Form and return it with your Appeal Form. Click here for our Appointment of Representative Form.

Depending on the nature and type of your appeal, we will notify you as follows.

Decisions on standard medical appeals - within 30 calendar days from the date we receive your request, but may be extended to 44 calendar days if additional information is necessary.

Decisions on standard appeals for Part D prescription drug coverage determination - within 7 calendar days from the date we receive your request.

Decisions on expedited medical appeals - within 72 hours of the date we receive your request.

Decisions on expedited appeals for Part D prescription drug coverage determination - within 24 hours from the date we receive your request.

Grievances
A grievance is the type of complaint you make if you have a problem with your health care provider or the service we provide to you. For example, you would file a grievance if you have a concern about things such as:

the quality of the medical care you receive;
problems with the time you spend waiting on the phone, in a waiting room or in an exam room;
problems with getting appointments in a timely manner, or having to wait a long time to have your prescription filled;
problems with our Customer Service;
disrespectful or rude behavior by pharmacists, providers or other medical staff;
the cleanliness or condition of pharmacies, providers offices, clinics or hospitals.

There are 2 kinds of Grievance requests: standard and expedited (rush).

A standard grievance request can be submitted verbally by calling 1-800-942-0247 (or TTY / TDD hearing impaired 1-866-816-2479), 8 a.m. to 8 p.m, 7 days a week, or in writing and sent to:
Community Health Plan
Attn: Community HealthFirst Grievance Coordinator
720 Olive Way, Suite 300
Seattle, WA 98101

An expedited grievance can be submitted in writing to the address above, or verbally by calling the number above. You should file an expedited grievance if your health or ability to function could be seriously harmed by waiting more than 72 hours (3 calendar days) for a decision.

You can also fax your grievance request to: 206-613-8983 or deliver it in person to the address listed above.

If you wish to file a Grievance in writing, click here for our Grievance Form. Be sure you clearly indicate which type of grievance you are making on the form. If you wish to have someone to act on your behalf, you must fill out our Appointment of Representative Form and return it with your Grievance Form. Click here for our Appointment of Representative Form.

Depending on the nature and type of your grievance, we will notify you as follows:

Decisions on standard grievance requests – within 30 calendar days from the date we receive your request, but may be extended if additional information is necessary.

Decisions on Part D prescription drug standard grievance requests– within 72 hours (3 calendar days) from the date we receive your request.

Decisions on expedited grievance requests – within 72 hours (3 calendar days) of the date we receive your request.

Decisions on Part D expedited grievance requests – within 24 hours from the date we receive your request.

Additional information on Appeals and Grievances can be found in the Evidence of Coverage (EOC) booklet.

EOC of the Medicare Advantage Plan (H5826 006) applies if you live in any of the following counties: Island, King, Kitsap, Pierce, Snohomish, Spokane, Thurston.

EOC of the Medicare Advantage Plan (H5826 007) applies if you live in any of the following counties: Adams, Benton, Chelan, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, Lewis, Lincoln, Mason, Okanogan, Pend Oreille, Skagit, Stevens, Walla Walla, Whatcom & Yakima

EOC of the Medicare Advantage Plan with Pharmacy (H5826 008) applies if you live in any of the following counties: Island, King, Kitsap, Pierce, Snohomish, Spokane, Thurston.

EOC of the Medicare Advantage Plan with Pharmacy (H5826 009) applies if you live in any of the following counties: Adams, Benton, Chelan, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, Lewis, Lincoln, Mason, Okanogan, Pend Oreille, Skagit, Stevens, Walla Walla, Whatcom & Yakima

EOC of the Medicare Advantage Special Needs Plan (H5826 005) applies to all the counties listed above.

Status information for Appeals and Grievances

For a status update on Appeals and Grievances call us 8 a.m. to 8 p.m, 7 days a week at: 1-800-942-0247 (or TTY/TDD hearing impaired call 1-866-816-2479)

To obtain an aggregate number of Appeals and Greivances filed with Community HealthFirst, please contact our Customer Service at the number above.

Prescription Drug Policies and Forms for requesting Formulary Exceptions and Coverage Determinations

This applies only to members who have our Medicare Advantage Plans with Pharmacy or our Medicare Advantage Special Needs Plan.

Requesting an exception if your drug is not on the Formulary
If your drug is not listed in the formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Community HealthFirst does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Community HealthFirst. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Community HealthFirst.
You can ask Community HealthFirst to make an exception and cover your drug. See the following section for information about how to request an exception.

You can ask Community HealthFirst to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Community HealthFirst limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

Generally, Community HealthFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Prior Authorization / Medication Exception Request Form.

Requesting a Coverage Determination
A Coverage Determination is a decision made by your health plan about the prescription drug benefits available in your specific plan and the cost you may pay for a specific drug.

If you would like your health care provider to make a Coverage Determination request on your behalf, click here for the Provider Coverage Determination Request Form.

You may also submit your own Coverage Determination request. If you would like to do so, click here for a copy of the Member Coverage Determination Request Form.

If you would like to request reconsideration of a decision made regarding coverage for your prescription drugs, click here for a copy of the Member Request for Medicare Prescription Drug Coverage Reconsideration Form.

Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.

Additional information on our Coverage Determination and Exception Policy for Prescription Drugs can be found in the Evidence of Coverage (EOC) booklet. Click on proper link below for the EOC of your plan and refer to the table of contents for the specific section on Coverage Determination.

EOC of the Medicare Advantage Plan with Pharmacy (H5826 008) applies if you live in any of the following counties: Island, King, Kitsap, Pierce, Snohomish, Spokane, Thurston.

EOC of the Medicare Advantage Plan with Pharmacy (H5826 009) applies if you live in any of the follow counties: Adams, Benton, Chelan, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, Lewis, Lincoln, Mason, Okanogan, Pend Oreille, Skagit, Stevens, Walla Walla, Whatcom & Yakima

EOC of the Medicare Advantage Special Needs Plan (H5826 005) applies to all the counties listed above.

Contact information for Prescription Drug Coverage Determination and Exception Requests

Call us at: 1-800-417-8164 or TTY / TDD hearing impaired call 1-800-899-2114

Fax us at: 1-877-837-5922

Send written requests to:

Express Scripts Prior Auth Department – Part D
Community Health Plan of Washington
Mail Route BL0345
6625 West 78th Street
Bloomington, MN 55439