Member Rights and Forms

Member Rights and Forms.

Quality Assurance Policy

The quality of our care and services is very important to Community, as is our Members’ safety. Our Quality Improvement Program uses things like quality scores, reports, and Member and Provider satisfaction surveys to see how we are doing.

Member Rights and Responsibilities

Our Responsibilities as Your Health Plan: 
Give you information about the plan, its network of providers, and your covered services. We must provide information in a way that works for you (in languages other than English, Braille, large print or other alternative formats).

Prior Authorization

For prior authorizations for certain services, your Provider must contact us by telephone, electronically or in writing to request appropriate authorization.

Direct Member Reimbursement (DMR) Form

Use these forms when you pay full price for a something you believe should have been covered by your plan. Complete the Part C Form for medical (doctor’s office) expenses and the Part D Form for pharmacy expenses.

Mail to:
Claims Payment Request
O. Box 301404
Houston, TX 77230-1404

Mail to: 
Manual Claims
P.O. Box 1039
Appleton, WI 54912-1039

CMS Appointment of Representative Form

To appoint a representative to act on your behalf, you may download this form or call Member Services for assistance.

H9826_IT_10045_092919_M Last updated September 30, 2019