Grievance & Appeals

Appeals
Standard Reconsideration and Appeal Process
Expedited Appeals
Grievances
Coverage Determination
Who Can Make A Complaint?
For More Information

You have the right to file a grievance or appeal if you have concerns or problems as a member of Wisconsin Personal Care Plan. We must be fair in how we handle your grievance or appeal, and cannot be disenrolled you or penalized in any way. We will try to resolve any complaint that you have over the phone. But if we cannot resolve your issue, we have a formal process to review your complaint. Appeals and grievances are two different types of complaints you can make. We will assist you with this process.

Appeals
An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what services or benefits are covered for you, what we will pay for a benefit or service, which prescription drugs are covered for you or what we will pay for a prescription drug. You have the right to appeal any decision we make about benefits and services you believe should be covered or paid. Examples of appeals include:

1. Reimbursement for coverage of emergency or urgently needed services.
2. A denied claim for services that you believe should have been reimbursed.
3. Coverage for an item or service that you have not received but which you believe should be covered.
4. Any decision to discharge you from the hospital if you believe it is too early to do so. (Note: In this case, a notice will be given to you with information about how to appeal to a MetaStar, the Medicare Quality Improvement Organization (QIO). You will remain in the hospital while MetaStar immediately reviews the decision. You will not have to pay for charges during this period, regardless of the outcome of the review. Refer to your Evidence of Coverage for more information.)
5. Reduced coverage for services that you believe is medically necessary.

An appeal can be submitted verbally or in writing.

Standard Reconsideration and Appeal Process
The appeal process deals with the Health Plan’s decision to deny a requested drug, service, or claim payment. When this happens, we will tell you in writing why your request was denied and how you can file an appeal. If you decide to file an appeal, the following steps will occur:

• Reconsideration is when you ask in writing, that the plan review its decision. You must a “reconsideration” within 60 days of the written notice.
• The plan has 60 days to make a decision. However, you or your doctor can ask for an expedited (fast) decision if your life or health is in serious jeopardy.
• When submitting your appeal you may include information which you believe may help with processing your appeal or help us rule in your favor.
• When we complete our review, we will send you a letter telling you about our decision.

If the Plan still decides to deny payment or services, we will send our decision to an independent agency (MetaStar) for their review. If MetaStar agrees with the Plan’s decision, you have the right to ask for a hearing before an Administrative Law Judge. You will receive a written decision from the Judge. If you are still dissatisfied, you may go to Federal Court for judicial review.

Expedited Appeals
When a doctor asks for an expedited appeal, the Plan will make a decision within 72 hours. We may extend this timeframe by up to fourteen (14) calendar days if you ask for the extension, or if the Plan needs more information and the extra time will benefit you. A doctor does not have to be part of our network to ask for an expedited decision on your behalf.

If you ask for an expedited decision without a doctor’s support, we will review your request and decide if it meets with the Medicare expedited appeal requirements. If we decide your request is not time sensitive (where your health is not seriously jeopardized), we will notify you verbally and in writing, and will begin processing your request under the standard appeal time frame.

Grievances
A “grievance” is the type of complaint you make if you are not satisfied with the services provided by Wisconsin Personal Care Plan, one of our plan providers or a network pharmacy.

Examples of grievances include:

• Problems with the quality of the medical care you receive, including quality of care during a hospital stay.
• If you feel that you are being encouraged to disenroll from the Health Plan.
• Problems with the Member Service you receive.
• Problems with how long you have to spend waiting on the phone, in the waiting room, in a network pharmacy or in the exam room.
• Problems with getting appointments when you need them, or having to wait a long time for an appointment.
• Disrespectful or rude behavior by doctors, nurses, receptionists, network pharmacists or other staff.
• Cleanliness or condition of doctor’s offices, clinics, network pharmacies or hospitals.
• If you disagree with our decision not to expedite your request for an expedited coverage determination, organization determination, redetermination or reconsideration.
• You believe our notices and other written materials are difficult to understand.
• Failure to give you a decision within the required timeframe.
• Failure to forward your case to an independent review entity when required or to give you a decision within the required timeframe.
• Failure by the Plan to provide required notices.

A grievance can be submitted verbally or in writing.

Coverage Determination
A coverage determination is when the Plan makes a decision about what services, benefits or prescription drugs are covered for you; what we will pay for those services, benefits or drugs; and what your share of the cost will be.

Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. A formulary exception can be requested by you or your appointed representative and the doctor who wrote the prescription. If you request an exception, your doctor must provide a statement to support your request. We will review your request if your doctor tells us that none of the drugs in our formulary (used to treat your condition) have adverse effects or are not as effective.

A request for a standard coverage determination is generally made in writing. A request for an expedited coverage determination can be made verbally or in writing. You, your appointed representative, or your prescribing physician may submit a request for a coverage determination.

Who can make a complaint?
Either you can file a complaint yourself, or you can name another person to act on your behalf. You can ask a relative, friend, advocate, doctor, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

For More Information
For more details regarding the grievance and appeal process, please review Sections 10, 11 or 12 of your ANOC/Evidence of Coverage.

Or you can call Member Services at 1-715-552-4300 or 1-888-203-7770 (toll free). Our normal business hours are Monday through Friday, 8:00 am - 5:00 pm; a voice mail system is available for all after hour calls from 5:00 pm - 8:00 pm, and during weekends and holidays. TDD/TTY: 1-800-947-3529