Located in Chapter 9, Section 11 of the 2025 Evidence of Coverage: How to make a complaint about quality of care, waiting times, customer service, or other concerns
To submit a grievance verbally, contact Customer Service at:(918) 594-5323 or 1-800-642-8065 ,
TTY/TDD: 1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
Located in Chapter 9, Section 6 of the 2025 Evidence of Coverage: Your Medical Care: How to ask for a coverage decision or make an appeal of a coverage decision .
To request a coverage decision verbally, contact Customer Service at 1-800-642-8065
or (918) 594-5323 (local);
TTY/TDD: 1-800-722-0353 , Monday through Friday from 8:00 am to 8:00 pm
Located in Chapter 9, Section 6 of the 2025 Evidence of Coverage: "How to ask for a coverage decision or make an appeal"
To request a coverage determination verbally, contact CVS Caremark Part D Exceptions Department at 1-866-270-3877 , TTY/TDD: 771, Monday through Friday from 8:00 am to 8:00 pm.
To submit a request in writing, send to:
Fax Number: 1-844-268-9791
A letter or the standardized Medicare Prescription Drug Coverage Determination Form may be used to submit a request. Click on the link to print this form.
Enrollees and Providers:
Located in Chapter 9, Section 5 of the 2025 Evidence of Coverage: Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision
If we make a coverage decision, whether before or after a benefit is received, and you are not satisfied, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
A standardized appeal request form is available. However, you may submit your request in any format. To print this form, click on the following link:
To submit an appeal request in writing, send to:
Senior Health Plan
Requests for appeals must be in writing unless the request is for a fast or expedited decision. Members must file their appeal request within 65 calendar days from the date included on the notice of the coverage decision.
Exceptions may be granted if you have a good reason for missing the deadline.1-800-642-8065
or (918) 594-5323 (local);
TTY/TDD: 1-800-722-0353 .
Monday through Friday from 8:00 am to 8:00 pm.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than
those who make the unfavorable decision. When we complete the appeal review, we will give you our decision in writing.
Located in Chapter 9, Section 7 of the 2025 Evidence of Coverage: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
Requests for Appeal Level 1 redeterminations must be in writing unless the request is for a fast or expedited decision.
Members must file their appeal within 65 calendar days from the date included on the notice of the coverage decision.
Exceptions may be granted if you have a good reason for missing the deadline.
To submit a fast appeal verbally, contact the Pharmacy Help Desk at:
918-594-5211 or
1-877-293-8628 , TTY/TDD:
1-800-722-0353 , Monday through Friday from 8:00 am to 8:00 pm
To submit a standard appeal in writing, send to:
Senior Health Plan
Attn: Grievance and Appeals Department
P.O. Box 3327, Tulsa, OK 74101-3327
Fax Number: 918-879-4048
In person:
CommunityCare Member & Resource Center
5235 S Sheridan Rd
Tulsa, OK 74145
A standardized Redetermination Request Form is available. However, you may submit your request in any format.
Located in Chapter 5, Section 4 of the 2025 Evidence of Coverage: There are restrictions on coverage for some drugs
For prescribing physicians to submit a prior authorization request verbally, contact CVS Caremark Part D Exceptions Department
at 1-866-270-3877 , TTY/TDD: 771, Monday through Friday from 8:00 am to 8:00 pm.
To submit a prior authorization in writing, send to:
Fax Number: 1-844-268-9791
Physicians may use the attached Prescription Authorization Form to request prior authorization. Click on the link to print a copy of this form to take to your physician.
Chapter 9, Section 7 of the 2025 Evidence of Coverage: Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
There is no standardized form for a prescribing physician to use to present supporting statements or documents.
For a prescribing physician to submit a supporting statement verbally, contact CVS Caremark Part D Exceptions Department at 1-866-270-3877 , TTY/TDD: 771, Monday through Friday from 8:00 am to 8:00 pm.
To submit supporting documents in writing, send to:
Fax Numbers: 1-844-268-9791
Questions about grievances, coverage decisions and appeals can be answered by our Customer Service Department.
Contact Customer Service at:
(918) 594-5323 or
1-800-642-8065
TTY/TDD:
1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 771,
available Monday through Friday from 8:00 am to 8:00 pm
For Coverage Decisions about Part D Prescription Drugs: contact CVS Caremark Part D Exceptions Department at
1-866-270-3877 , TTY/TDD: 771, Monday through Friday from 8:00 am to 8:00 pm.
For Coverage Decisions about Medical Care: contact Customer Service at
(918) 594-5323
or
1-800-642-8065
TTY/TDD:
1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 771,
available Monday through Friday from 8:00 am to 8:00 pm
For Part D or Part C Appeal status: contact Customer Service at:
(918) 594-5323
or
1-800-642-8065
TTY/TDD:
1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 771,
available Monday through Friday from 8:00 am to 8:00 pm
For Part D or Part C Grievance status: contact Customer Service at
(918) 594-5323
or
1-800-642-8065
TTY/TDD:
1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 771,
available Monday through Friday from 8:00 am to 8:00 pm
Located in Chapter 9, Section 5 of the 2025 Evidence of Coverage:
A guide to the basics of coverage decisions and appeals
If you have someone appealing our decision for you other than your doctor, your appeal must include an Appointment of Representative form authorizing this
person to represent you. A completed standardized form is required in order to appoint a representative. To print this form, click on the following link:
This form is also available on Medicare's website at
http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf .
Instructions for completing the Appointment of Representative form:
The member (beneficiary) completes the requested information in Section I including the name of the individual they appoint as their representative.
The beneficiary's signature is required.
This section is completed by the individual the beneficiary has named as their representative. The representative's signature is required.
These sections may not apply. See page 2 of the form for further information.
To submit a completed Appointment of Representation Form, send to:
For all Appeals
Senior Health PlanP.O. Box 3327 Tulsa, OK 74101-3327
For Part C Coverage Determinations and Exceptions
Oklahoma Dual CompleteP.O. Box 3327 Tulsa, OK 74101-3327
For Part D Coverage Determinations and Exceptions
Navitus Health Solutions
In person
4720 S. Harvard, Suite 101, Tulsa, OK 74135 (Senior Center)
For information on how to obtain an aggregate number of grievances and appeals, contact Customer Service at:
(918) 594-5323 or
1-800-642-8065
TTY/TDD:
1-800-722-0353 ,
Monday through Friday from 8:00 am to 8:00 pm
OR
TTY/TDD: 771,
available Monday through Friday from 8:00 am to 8:00 pm
For additional detail on coverage decisions, complaints and appeals, the following sections in Chapter 9 are located in your 2025 Evidence of Coverage :
Section 5 -
A guide to the basics of coverage decisions and appeals.
Section 6 -
Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision.
Section 7 -
Your Part D prescription drugs: How to ask for a coverage decision or make an appeal.
Section 8 -
How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon.
Section 9 -
How to ask us to keep covering certain medical services if you think your coverage is ending too soon.
Section 10 -
Taking your appeal to Level 3 and beyond.
Section 11 -
How to make a complaint about quality of care, waiting times, customer service, or other concerns.
Section 12 -
Handling problems about your Medicaid benefits
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