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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.

In Allegheny County the member should contact Community Care, to initiate the external review, 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
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In the Capital region, the member should contact Community Care to initiate the external review, at:
Adams County                      1-866-738-9849
Berks County                       1-866-292-7886
York County                        1-866-542-0299
        Or write to:
Community Care Behavioral Health Organization                                                       Attention: Manager of Complaints and Grievances
PO Box 1266
Camp Hill, PA 17011
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In Chester County, the member should contact Community Care to initiate the external review, at 1-866-622-4228, or write to:
Community Care Behavioral Health Organization                                                            Attention: Manager of Complaints and Grievances
One East Uwchlan Avenue, Suite 311
Exton, PA 19341
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In the North East area (Lackawanna, Luzerne, Susquehanna, and Wyoming Counties), the member should contact Community Care to initiate the external review, at: 1-866-668-4696, or write to:
Community Care Behavioral Health Organization                                                  Attention: Manager of Complaints and Grievances
72 Glenmaura National Blvd, 2nd Floor
Moosic, PA 18507
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In the North Central region (Bradford, Cameron, Centre, Clarion, Clearfield, Columbia, Elk, Forest, Huntingdon, Jefferson, Juniata, McKean, Mifflin, Montour, Northumberland, Potter, Schuylkill, Snyder, Sullivan, Tioga, Union, Warren, and Wayne Counties), the member should contact Community Care to initiate the external review, at: 1-866-878-6046 or:

Residents of Cameron, Clarion, Clearfield, Elk, Forest, Jefferson, McKean, Potter, and Warren should write to:
Community Care Behavioral Health Organization                                                            Attention: Manager of Complaints and Grievances
480 Jeffers Street, Developac Business Park, Building #2
DuBois, PA 15801

Residents of Bradford, Columbia, Montour, Northumberland, Schuylkill, Snyder, Sullivan, Tioga, Union, and Wayne should write to:

Community Care Behavioral Health Organization                                                  Attention: Manager of Complaints and Grievances
72 Glenmaura National Blvd, 2nd Floor
Moosic, PA 18507

Residents of Centre, Huntingdon, Juniata, and Mifflin should write to:

Community Care Behavioral Health Organization                                                          Attention: Manager of Complaints and Grievances
2505 Green Tech Drive, Suite F
State College, PA 16803
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In the Carbon/Monroe/Pike area the member should contact Community Care to initiate the external review, at: 1-866-473-5862, or write to:

Community Care Behavioral Health Organization                                                       Attention: Manager of Complaints and Grievances
The Courtyard Professional Art Building, 300 Community Drive, Suite F
Tobyhanna, PA 18466

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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