Table 21-10, Clinical Appeal - Expedited

Commercial Plans
BENEFIT PLAN(S)	WHAT/HOW/WHERE TO FILE: INSTRUCTIONS	TIME FRAMES			ADDITIONAL RIGHTS
BENEFIT PLAN(S)	WHAT/HOW/WHERE TO FILE: INSTRUCTIONS	Initial Member/ Provider* Filing	ConnectiCare Acknowledges Receipt	ConnectiCare Determination Notification	ADDITIONAL RIGHTS
ConnectiCare	Unless otherwise directed in the denial letter, write to: ConnectiCare Grievance and Appeal Dept. P.O. Box 4061 Farmington, CT 06034 Telephone: 800-251-7722	180 calendar days from receipt of written adverse determination.	N/A	Monday through Wednesday – 48 hours from receipt for pre-service requests; If additional information is needed the case can be extended to 72 hours. Thursday through Sunday or holiday 72 hours for pre-service receipt;	External appeal if applicable
ConnectiCare of Massachusetts	ConnectiCare Grievance and Appeal Dept. P.O. Box 4061 Farmington, CT 06034 Telephone: 800-251-7722	180 calendar days from receipt of written adverse determination.	N/A	72 hours from receipt	External appeal

Medicare Plans
BENEFIT PLAN(S)	WHAT/HOW/WHERE TO FILE: INSTRUCTIONS	TIME FRAMES			ADDITIONAL RIGHTS
		Initial Member/ Provider* Filing	ConnectiCare Acknowledges Receipt	ConnectiCare Determination Notification
ConnectiCare	Unless otherwise directed in the denial letter, write to: ConnectiCare Grievance and Appeal Dept. P.O. Box 4061 Farmington, CT 06034 Telephone: 800-224-2273	60 calendar days from receipt of written adverse determination.	N/A	72 hours from receipt for pre-service requests	Medical: Maximus Federal Services Pharmacy: C2C Innovative Solutions, Inc.