We take your concerns seriously and consider them opportunities to improve care and service.

As a Community HealthFirst Medicare Advantage Plan enrollee, you have the right to voice a complaint if you have a problem or concern about your health care or health care coverage. 

The following is an overview of the procedures to file Appeals, Coverage Determinations, and Grievances.

Please read our complete Community HealthFirst Appeals & Grievances Policy Handbook in English or Spanish. If you are enrolled in our MA Special Needs Plan (014), please read the Appeals and Grievances booklet for your plan.

You will need Adobe Acrobat Reader to view the PDF documents on this website. Download Adobe Acrobat Reader for free.

You always have the option to contact CMS directly with your concerns by calling them at 1-800-MEDICARE, or through their website at: www.medicare.gov/MedicareComplaintForm/home.aspx

Appeals and Coverage Determinations

What is an Appeal?

An appeal is when you want us to reconsider a decision we have made about what benefits are covered under your plan or what we will pay.

For example, you might appeal if you think we:

  • will not approve payment for care you believe should be covered;
  • are stopping payment for care you need; or,
  • have not paid for a particular medical procedure or service you think should be covered.

What is a Coverage Determination?

A coverage determination is the first step you take in requesting a ruling on a Part D prescription drug benefit. When we make a coverage determination, we are making a decision whether or not to pay for a Part D drug and what your share of the cost is. 

You can also request a coverage determination on a Part D prescription drug through the appeal process.

You can find the Part D coverage determination form, redetermination forms, and exception request form here.

How to file an Appeal or Coverage Determination

If you wish to file an Appeal or Coverage Determination, it must be done within 60 days of the notice of denial date.  There are two kinds of appeals: standard and expedited (rush).

Standard Appeals/Coverage Determinations

A standard appeal/coverage determination request must be in writing and sent to:

Community Health Plan of Washington
Attn: Community HealthFirst Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101

Expedited Appeals/Coverage Determinations

You should file an expedited appeal if your health or ability to function could be seriously harmed by waiting more than 72 hours (or three calendar days) for a decision.

Expedited Appeals/Coverage Determinations can be submitted:

In Writing: Community Health Plan of Washington
Attn: Community HealthFirst Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101

Verbally: 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m., 7 days a week.  

By Fax: 206-613-8983

In Person at 1111 Third Avenue, Suite 400, Seattle WA 98101

Appeal and Coverage Determination Notification Process

Depending on the nature and type of your appeal, we will notify you as follows.

Standard appeals are processed within 30 calendar days from the date we receive your request, but may be extended to 44 calendar days if additional information is needed. You will receive notice of our decision in writing along with any supporting explanation.

Decisions on standard appeals for Part D prescription drug coverage determination are made within 7 calendar days from the date we receive your request.

Decisions on expedited appeals are made within 72 hours of the receipt of the appeal. If we determine that the appeal should be standard instead, we will promptly call you with that decision and follow up with a written notice within two calendar days.

Decisions on expedited appeals for Part D prescription drug coverage determination are made within 24 hours from the date we receive your request.

To check on the status of your Appeal or Coverage Determination, call us at 1-800-942-0247 (TTY Relay: 7-1-1) from 8:00 a.m. to 8:00 p.m., 7 days a week.

Grievances

What is a Grievance?

A grievance is a complaint you make if you have a problem with your health care provider or the service we provide to you. For example, you would file a grievance if you have a concern about things such as:

  • the quality of your care;
  • waiting times for appointments or in the waiting room;
  • your provider's behavior;
  • the ability to reach someone by phone or get the information you need;
  • the cleanliness or condition of your provider's office; or,
  • the courtesy of services we provide you.

How to file a Grievance

There are two kinds of grievance requests: standard and expedited (rush).

Standard Grievances

Standard grievances can be submitted:

Verbally: 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m, 7 days a week

In Writing to: 

Community Health Plan of Washington
Attn: Community HealthFirst Grievance Coordinator
1111 Third Avenue, Suite 400
Seattle, WA 98101

By Fax: 206-613-8983

In Person: Deliver your request to Community Health Plan of Washington, 1111 Third Avenue, Suite 400, Seattle WA, 98101

Expedited Grievances

You should file an expedited grievance if your health or ability to function could be seriously harmed by waiting more than 72 hours (three calendar days) for a decision.

An expedited grievance can be submitted:

In Writing to:

Community Health Plan of Washington
Attn: Community HealthFirst Grievance Coordinator
1111 Third Avenue, Suite 400
Seattle, WA 98101

Verbally: 1-800-942-0247 (TTY Relay: 7-1-1), 8:00 a.m. to 8:00 p.m, 7 days a week

By Fax: 206-613-8983

In Person: Deliver your request to Community Health Plan of Washington, 1111 Third Avenue, Suite 400, Seattle WA, 98101

Grievance Notification Process

Depending on the nature and type of your grievance, we will notify you as follows:

Standard grievance requests are typically decided upon within 30 calendar days from the date we receive your request, but may be extended if additional information is needed. Grievances filed verbally are responded to verbally. Grievances filed in writing and all quality of care grievances are responded to in writing.

Decisions on Part D prescription drug standard grievance requests are made within 30 days.

Decisions on expedited grievance submittals are made within 72 hours (three calendar days) of the receipt of the request. If we determine that the grievance should be standard instead, we will promptly call you with that decision and follow up with a written notice within two calendar days.

Decisions on Part D expedited grievance requests are made within 24 hours.

To check the status of your Grievance, call us at 1-800-942-0247 (TTY Relay: 7-1-1) from 8:00 a.m. to 8:00 p.m., 7 days a week.

Information and Forms

Medical and Plan Forms

Prescription Drug Forms

Prior Authorization Information and Forms

To obtain an aggregate number of Appeals and Grievances filed with Community HealthFirst, please contact our Customer Service at 1-800-942-0247 (TTY Relay: 7-1-1) from 8:00 a.m. to 8:00 p.m., 7 days a week.

You can also learn more about what happened to formal complaints filed with Community HealthFirst by reading our current Appeals and Grievances Report.

Medicare Beneficiary Ombudsman

The Medicare Beneficiary Ombudsman helps you with complaints, grievances, and information requests. The Medicare Beneficiary Ombudsman makes sure information is available about the following:

  • What you need to know to make health care decisions that are right for you
  • Your rights and protections under Medicare
  • How you can get issues resolved

For more information, visit: http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html.