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Medicaid SSI & BadgerCare Plus Grievances

 

A grievance is any expression of dissatisfaction by a member or member’s authorized representative about:

  • iCare services or procedures
  • a contracted provider’s services or procedures
  • services arranged by iCare or a contracted provider

Independent Care Health Plan treats every complaint as a grievance. This means that iCare will keep track of member complaints, take your concerns seriously and make sincere efforts to resolve them.

Dissatisfaction with a determination of coverage is not considered a grievance but may be treated as an appeal. It is iCare’s responsibility to determine whether your complaint is a grievance or an appeal or has pieces of both.

How to File a Grievance

If you have a grievance, you are encouraged to call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529). iCare accepts both oral and written grievances. iCare will try to resolve any complaint that you might have over the phone. iCare will notify you in writing within 10 business days that your grievance has been received. If iCare cannot resolve your complaint over the phone, the iCare Grievance and Appeal Coordinator will conduct an investigation. Members have a right to be heard before the iCare Grievance and Appeal Committee.  At the conclusion of the grievance process, you will receive a letter explaining how iCare resolved your grievance.

If you want your grievance to be in writing, please send it to:

Independent Care Health Plan
Attention: Member Grievances
1555 N. RiverCenter Dr., Suite 206
Milwaukee, WI 53212

OR

Fax:  414-918-7589

 

iCare must notify you of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days after receiving your complaint. iCare may extend the timeframe by up to 14 calendar days if you request the extension, or if iCare is able to justify a need for additional information and the delay is in your best interest.

iCare cannot treat you in a different way because you file a complaint. Your health care benefits will not be affected. iCare will provide all non-English speaking and hearing-impaired members with interpreter services during the grievance process.

If you would like to inquire about the status of a grievance you filed with iCare, please call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529).

Filing a Grievance with the State

You can also file a grievance with the State.  To file a grievance with the State you can call 1-800-760-0001 or write to:

Wisconsin Medicaid
Managed Care Ombudsman
P.O. Box 6470
Madison, WI 53716-0470

 

Medicaid SSI & BadgerCare Plus Appeals

 

You cannot request a State Fair Hearing until you have exhausted all of your appeal rights with iCare.  If iCare does not make a determination on your appeal within the time frames indicated below, you are deemed to have exhausted iCare’s appeal process and you can then file a fair hearing.

 

Two Types of Appeals

 

Standard: iCare makes standard appeal decisions no later than 30 calendar days from receiving the written request for an appeal. iCare may extend the timeframe by up to 14 calendar days if you request the extension, or if iCare is able to justify a need for additional information and the delay is in your best interest.

Expedited (Fast) Appeal: You can ask for an expedited appeal if you feel your life or health could be in jeopardy by waiting the standard timeframe. Expedited appeals can be transferred to the standard timeframe if it is determined your life or health is not in serious jeopardy. If the request for a fast appeal is denied, you will be notified in writing of your right to file a grievance. 

If iCare agrees that your appeal should be expedited, it will follow the same steps as a standard appeal, except that the appeal process will be completed within 72 hours from receiving the appeal request.  iCare may extend the timeframe by up to 14 calendar days if you request the extension, or if iCare is able to justify a need for additional information and the delay is in your best interest.

Appeals must be submitted within 60 calendar days from the date on the iCare denial notice by writing to:

Grievance and Appeal Coordinator
Attention: Member Appeals
Independent Care Health Plan
1555 N. RiverCenter Dr., Suite 206
Milwaukee, WI 53212-3958

OR

Fax:  414-918-7589

 

What Happens Next

 

Within 30 calendar days of receiving your appeal (or an additional 14 days if there has been an extension), iCare will make a decision about your appeal and you will receive written notice of our decision.  If we determine we made an incorrect decision, iCare will authorize the services.  If we determine we were correct to deny your services, you can then ask for a State Fair Hearing.

 

Fair Hearing

Once you have exhausted iCare’s appeal process, if you are still not happy with iCare’s decision, you can ask for a State Fair Hearing by sending a written request to:

Department of Administration
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707

OR

Fax: 608-264-9885

 

If you need a special arrangement for a disability or language translation, please call 1- 608-266-3096 (voice) or 1-608-264-9853 (hearing impaired). If you choose to request a Fair Hearing with the State of Wisconsin’s Division of Hearings and Appeals, you will have a hearing with an independent judge. You may bring an advocate, friend, family member or witnesses. You may also present evidence at this hearing. If you request a State Fair Hearing, your appeal will automatically go through a Department of Health Services review.

 

Help with Understanding Your Rights, or Help with Filing a Grievance or Appeal

 

iCare has a Member Advocate that can help you understand your rights and/or help you file a grievance or appeal. The iCare Member Advocate contact information is below:

 

Member Advocate
Independent Care Health Plan
1555 North RiverCenter Dr., Suite 206
Milwaukee, WI 53212

Phone: 414-231-1076
Toll Free: 800-777-4376
TTY: 800-947-3529
Fax: 414-231-1090
E-mail: advocate@iCareHealthPlan.org

 

 

You may also contact the following resources for information or assistance:

 

IC200_v2 DHS Approved for use on 7/1/2020
Last Updated 7/1/2020

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