Fillable Member Request, Appeal or Complaint Form part of (CalOptima)

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Member Request, Appeal or Complaint Form part of (CalOptima)

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Member Request, Appeal or Complaint Form
Use this form to request a coverage decision, appeal, or to file a formal complaint for any
part of care or service you had from OneCare.
Complete and return this form to us in
person, by mail or fax to 1-714-481-6499.
Print clearly or type below:
Member Name (First) (Middle initial) (Last) CIN #
Mailing Address (City) (Sta
te)
(Zip Code)
(_____)________________________ ______________________________
Pho
ne Number Date of Birth
(MM/DD/YY)
Briefly describe the reason for your appeal, complaint, or request (including requests for
exception of our drug coverage) -
state the service, drug name, dates, times, persons,
places, etc. Provide exact details and use a second sheet of paper if needed. Attach copies
of any letters, details or records that will support your complaint or request. Be sure to write
your name and CIN# on all pages.
Date______________ Signature________________________________________
If you have any questions, please call the OneCare (HMO SNP) Customer Service
Department toll-free at 1-877-412-2734, 24 hours a day, 7 days a week or visit our office
Monday through Friday 8:00 a.m. to 5:00 p.m. at 505 City Parkway West
, Orange, CA
92868. TTY/TDD users please call 1-800-735-2929.
Note: If you have someone other than your doctor or prescriber file your request, please
complete and submit the Appointment of Representative Form which can be printed from
the CalOptima OneCare website at www.caloptima.org
or by calling the OneCare Customer
Service Department toll-free at 1-877-412-2734. Please refer to your Evidence of Coverage
book for complete information on what to do if you have a problem or complaint.
H5433_08407 CMS Approved 05042011
click to sign
signature
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What If I Don’t Agree With This Decision?
You have the right to appeal. File your appeal in writing within 60 calendar days after
the date of this notice. We can give you more time if you have a good reason for
missing the deadline.
Who May File an Appeal?
You or your treating physician may file an appeal. You can name a relative, friend,
advocate, attorney, doctor (other than your treating physician), or someone else to act
as your representative. Others also already may be authorized under State law to act
for you.
If you have any questions, please call the OneCare Customer Service Department toll-
free at 1-877-412-2734, 24 hours a day, 7 days a week or visit our office Monday
through Friday, 8:00 a.m. to 5:00 p.m. Members with speech or hearing impairments
can call 1-800-735-2929.
If you want someone to act for you, you and your authorized representative must sign,
date, and send us a statement naming that person to act for you.
Form No. CMS-10003-NDMC OMB Approval No. 0938-0829
Important Information About Your Appeal Rights
For more information about your appeal rights, call us or see your Evidence of
Coverage.
There are two kinds of appeals you can
file:
Standard (30 days) – You can ask for a
standard appeal. We must give you a
decision no later than 30 days after we get
your appeal. (We may extend this time by
up to 14 days if you request an extension,
or if we need additional information and
the extension benefits you.)
Fast (72 hour review) – You can ask for a
fast appeal if you or your doctor believe
that your health could be seriously harmed
by waiting too long for a decision. We
must decide on a fast appeal no later than
72 hours after we get your appeal. (We
may extend this time by up to 14 days if
you request an extension, or if we need
additional information and the extension
benefits you.)
• If any doctor asks for a fast appeal for
you, or supports you in asking for one,
and the doctor indicates that waiting for
30 days could seriously harm your
health, we will automatically give you
a fast appeal.
• If you ask for a fast appeal without
support from a doctor, we will decide if
your health requires a fast appeal. We
will notify you if we do not give you a
fast appeal, and we will decide your
appeal within 30 days.
What Do I Include With My Appeal?
Your written request should include: your
name, address, member number, reasons
for appealing, and any evidence you wish
to attach. You may send in supporting
medical records, doctors’ letters, or other
information that explains why we should
provide the service. Call your doctor if you
need this information to help you with your
appeal. You may send this information or
present this information in person.
How Do I File an Appeal?
For a Standard Appeal: You or your
authorized representative should mail or
deliver your written appeal to the
address(es) below:
Grievance & Appeal Resolution Services
CalOptima
505 City Parkway West
Orange, CA 92868
For a Fast Appeal: You or your
authorized representative should contact us
by telephone or fax:
1-877-412-2734
What Happens Next? If you appeal, we
will review our decision. After we review
our decision, if any of the services you
requested are still denied, Medicare will
pr
ovide you with a new and impartial review
of your case by a reviewer outside of
OneCare. If you disagree with that
decision, you will have further appeal
rights. You will be notified of those appeal
rights if this happens.
Contact Information:
If you need information or help, call us
Monday through Friday, 8:00 a.m. to 5:30
p.m. at:
Toll Free: 1-877-412-2734
TTY/TTD: 1-800-735-2929
Other Resources To Help You:
Medicare Rights Center:
Toll Free: 1-888-HMO-9050
Elder Care Locator:
Toll Free: 1-800-677-1116
1-800-MEDICARE (1-800-633-4227)
TTY/TTD: 1-877-486-2048
Form No. CMS-10003-NDMC OMB Approval No. 0938-0829
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Completed 11 March 2021

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