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Independent External Appeals for Utilization Management Decisions

Under specific circumstances determined by Pennsylvania law, a member or member representative, which may include the member’s provider, with proof of the member’s written authorization for the representative to be involved and/or take action on the member’s behalf, can request an independent external review of a medical necessity decision (denial) through a process managed by the Pennsylvania Department of Health.

To initiate the external review, the member should contact Community Care (Allegheny County) at 1-800-553-7499, or write to:

Community Care Behavioral Health Organization
Attention: Manager of Complaints and Grievances
One Chatham Center, Suite 700
Pittsburgh, PA 15219

To initiate the external review, the member should contact Community Care (York, Adams, and Berks County) at 1-866-292-7886, or write to:

Community Care Behavioral Health
PO Box 1266
Camp Hill PA 17001-1266

To initiate the external review, the member should contact Community Care (Chester County) at 1-866-622-4228, or write to:

Community Care Behavioral Health Organization
One East Uwchlan Avenue, Suite 311
Exton, PA 19341
Attn: Complaints/Grievance Coordinator

A member or member representative may ask for an external review of Community Care’s Level 2 Grievance decision within 15 days from the date on their Level 2 grievance decision notice (to request an independent external review, a member must complete Community Care’s Level 1 and Level 2 Grievance process). An independent external review is a review by a licensed physician who does not work for Community Care.

If a member needs help filing a request for an external review, he/she can call Community Care at the number listed above for the appropriate county. Community Care will assign someone who has not been involved in the grievance issue to help the member.

A decision will be issued within 60 days from when the Department of Health assigns the case to an Independent External Review Organization.

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