As a member of Cooperative Advantage, you must use network providers. If you receive unauthorized care from an out of network provider, we may deny coverage and you will be responsible for the entire cost.

An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (i.e. Cooperative Advantage) regarding: 

1. Receipt of, or payment for, a managed care item or service; 

2. The amount a health plan requires an enrollee to pay for an item or service; or 

3. A limit on the quantity of items or services. 

You may file a standard reconsideration if you disagree with the decision that was made by Cooperative Advantage.

An enrollee, an enrollee’s representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filling an oral or written request with Cooperative Advantage. Expedited requests may be requested by an enrollee, an enrollee’s representative or any physician, regardless of whether the physician is affiliated with Cooperative Advantage. 

An organization determination made by Cooperative Advantage can be requested with respect to any of the following: 

• Payment for temporarily 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 other than Cooperative Advantage that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by Cooperative Advantage; 

• Cooperative Advantage’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged by Cooperative Advantage; 

• Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; or 

• Failure of Cooperative Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee. 
   

The way you submit an organization redetermination depends on when your service is happening. If you are requesting an organization: 

• Before the service is performed: This is considered an authorization request. Typically, authorization requests should be performed by your provider. For more information, please contact our Member Services department at (800) 460-4641. TTY users contact (711). 

• After a service is provided: This is considered a claim. Your provider should submit a claim on your behalf.  

Please allow three to five (3-5) business days for a standard organization determination request from the date it gets your request to notify you of it’s decision. Please contact member services for all expedited authorization requests.

A reconsideration is also known as an appeal. If Cooperative Advantage denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration. 

A reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence and findings upon which it was based, and any other evidence that the parties submit or that is obtained by the health plan, the QIO, or the independent review entity.    

• A non-contract physician or provider to a Medicare Health plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf. 

• Non-contract providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal. 

• A physician regardless of whether the physician is affiliated with the plan may request that a Medicare Health Plan expedite a reconsideration. 
   

• Reconsideration requests must be filed with the health plan within 60 calendar days from the date of the notice of the organization determination. 

• Expedited requests can be made either orally or in writing. 

• Standard requests must be made in writing unless the enrollee’s plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests. 

A party must file the request for reconsideration within sixty (60) calendar days from the date of the notice of the organization determination. If a request for reconsideration is filed beyond the sixty (60) calendar day time frame and good cause for late filing is not approved, Cooperative Advantage will forward the request to the independent review entity for dismissal. 

Once the plan receives the request, it must make it’s decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard requests, or 60 calendar days for payment requests. 

Our plan can accept or deny your request. If we approve your request for a standard reconsideration, our approval is valid until the end of the plan year.  

You or your representative can request a reconsideration by writing directly to us at: 

• Cooperative Advantage – Appeals and Grievances 
  2503 N. Hillcrest Parkway 
  Altoona, WI 54720 

• Fax: (715) 836-7683 
   

If a party shows good cause, Cooperative Advantage may extend the time frame or filing a request for reconsideration (i.e. appeal). Cooperative Advantage will consider the circumstance that kept the enrollee or representative from making the request on time and whether any organizational actions might have misled the enrollee. 

Examples of circumstances where good cause may exist to file a late appeal include (but are not limited to) the following situations: 

• The enrollee did not personally receive the adverse organization determination notice, or he/she received it late; 

• The enrollee was seriously ill, which prevented a timely appeal; 

• There was a death or serious illness in the enrollee’s immediate family; 

• An accident caused important records to be destroyed; 

• Documentation was difficult to locate within the time limits; 

• The enrollee had incorrect or incomplete information concerning the reconsideration process; or 

• The enrollee lacked capacity to understand the time frame for filing a request for reconsideration. 

An appeal is a formal request by the member (or his/her authorized representative) to change a decision previously made by Cooperative Advantage. 

For example, you may file an appeal for any of the following reasons:  

• Cooperative Advantage refuses to cover or pay for services you think Cooperative Advantage should cover. 

• Cooperative Advantage or one of the Contracting Medical Providers refuses to give you a service you think should be covered. 

• Cooperative Advantage or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving. 

• If you think that Cooperative Advantage is stopping your coverage too soon. 

You or your authorized representative may file an appeal. You may also have your physician file an appeal on your behalf. 

You may appoint an individual to act as your representative to file the grievance or an appeal for you by following the steps below. 

Provide our health plan with: 

1. Your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from Cooperative Advantage and/or CMS regarding the denial or discontinuation of medical services.” 

2. Your name, address and phone number and that of your representative, if applicable. 

3. A signed and dated statement by you and the person you are appointing as representative. 

4. You must include this signed statement with your appeal. 

5. Reasons for appealing, and any evidence you wish to attach. 

6. Supporting medical records, doctors’ letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish. 
    

You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. 

Note: The sixty (60) day limit may be extedned for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.   

Yes, you may file an expedited appeal by calling: (800) 460-4641. TTY users contact (711). 

A “time-sensitive” situation is a situation where waiting for a decision to be made within the time frame of the standard decision-making process could seriously jeopardize 1) your life or health, or 2) your ability to regain maximum function. 

If Cooperative Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Cooperative Advantage or your Primary Care Physician will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request. 

You may file a standard appeal to:  

Cooperative Advantage – Appeals and Grievances 
2503 N. Hillcrest Parkway 
Altoona, WI 54720 
 

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Cooperative Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.   

A grievance is a type of complaint that does not involve payment or denial of services by Cooperative of Advantage or a Contracting Medical Provider. For example, you would file a grievance if: 

• You have a problem with things such as the quality of your care during a hospital stay; 

• You feel you are being encouraged to leave your plan; 

• Waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; 

• Waiting too long for prescriptions to be filled; 

• The way your doctors, network pharmacists or others behave; 

• Not being able to reach someone by phone or obtain the information you need; or 

• Lack of cleanliness or the condition of the office. 
   

A grievance may be filed by any of the following: 

• You may file a grievance. 

• Your authorized representative. 
   

You May file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. There is no filing limit for complaints concerning quality of care. Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day time frame.    

If you would like you can file a complaint directly to Medicare by filling out the complaint form at https://www.medicare.gov/MedicareComplaintForm/home.aspx. You may file a standard grievance in writing directly to: 

Cooperative Advantage – Appeals and Grievances 
2503 N. Hillcrest Parkway 
Altoona, WI 54720 

You also may file a grievance by faxing (715) 836-7683 or calling our Member Services Department at (800) 460-4641. TTY users contact (711).

You have the right to request the number of appeals and the number of quality of care grievances received by Cooperative Advantage during a plan year. Please call Member Services at  (800) 460-4641. TTY users contact (711). or fax (715) 836-7683.   

You or someone you name may file a complaint (grievance) or appeal for you. The person you name would be your “appointed representative”. You may name a relative, friend, lawyer, advocate, health care provider, or anyone else to act on your behalf. 

To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696). Once you have filled out the form, you may print and mail the form to: 

Cooperative Advantage 
2503 N. Hillcrest Parkway 
Altoona, WI 54720 

You may also send a fax to (715) 836-7683.   

Ending your Membership in Cooperative Advantage may be voluntary (your own choice) or involuntary (not your own choice). If you are leaving our plan, you must continue to get your medical care through our plan until your Membership ends. 

For more complete information about disenrolling from Cooperative Advantage, you can do any of the following: 

See your Evidence of Coverage for more information and to learn about the rights, benefits, and responsibilities of Members. 

Read the Medicare & You Handbook. Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. You can also download a copy from the Medicare website (www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below. 

Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Calls to these numbers are free.