Part C Appeals
As a member of OneCare, you, your doctor or your representative can file an appeal if OneCare makes a decision to not pay for, not approve or stop a service you think should be covered or provided to you. This could include denials for referrals to see a specialist, for durable medical equipment or involving payment for services you received or believe you should receive under the OneCare program (including co-payments and billing issues or reimbursement).
You must file your appeal within 60 days of the date of the notice of denial. The filing timeline can be extended if you show good cause for the delay in filing your appeal. To appeal a decision, please contact the OneCare Customer Service Department by calling 1-877-412-2734, 24 hours a day, 7 days a week (TTY/TDD users call 1-800-735-2929), or visit our office Monday through Friday, from 8 a.m. to 5 p.m., or fax the grievance to 1-714-481-6499. You can also send your written appeal to:
Grievance and Appeals Resolution Services
OneCare (HMO SNP)
505 City Parkway West
Orange, CA 92868
OneCare will review your appeal and send you a letter telling you the review decision within 30 days of receiving your pre-service appeal. If you are appealing a payment denial, OneCare will review and send you a letter telling you the review decision within 60 days of receiving your appeal. You or your representative can also provide information about your complaint in person about your appeal by contacting our OneCare Customer Service Department.
If you think your health could be seriously harmed by waiting for a decision about a service, you can request a faster decision, which is issued within 72 hours of receiving your appeal. In both cases, you will receive a written notice of the outcome of your appeal, including any additional appeal rights which include, when necessary, an independent review entity, such as hearings before an Administrative Law Judge, review by the Medicare Appeals Council and judicial review.