An appeal is a request for a review of an adverse benefit determination. An adverse benefit determination is any of the following:
- iCare plans to stop, suspend, or reduce a service you are currently getting.
- iCare decides to deny a service you asked for.
- iCare decides not to pay for a service.
- iCare asks you to pay an amount that you don’t believe you owe.
- iCare decides to deny your request to get a service from a non-network provider when you live in a rural area that has only one health maintenance organization.
- iCare fails to arrange or provide services in a timely manner.
- iCare fails to meet the required timeframes to resolve your grievance or appeal.
Your authorized representative or your provider may request an appeal for you if you have given them consent to do so. When requesting an appeal, you must appeal to iCare first. The request for an appeal must be made no more than 60 days from the date on the written adverse benefit determination notice.
If you need help writing a request for an appeal, please call your iCare Member Advocate at 1-800-777-4376, or the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocacy Project at 1-800-928-8778 for help with your appeal.
If you disagree with iCare’s decision about your appeal, you may request a fair hearing with the Wisconsin Division of Hearing and Appeals. The request for a fair hearing must be made no more than 90 days after the date you receive iCare’s written decision about your appeal.
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
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.
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
If you need help writing a request for a fair hearing, please call either the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocacy Project at 1-800-928-8778 for help.
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.
You may request to have the disputed services continued while the iCare appeal and State fair hearing process are occurring. The request to continue services must happen on or before the later of the following:
- Within 10 days of receiving the notice that services were denied or changed, or
- Before the effective date of the denial or change in benefits. You may need to pay for the cost of services if the hearing decision is not in your favor.
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:
Independent Care Health Plan
1555 North RiverCenter Dr., Suite 206
Milwaukee, WI 53212
Toll Free: 800-777-4376
You may also contact the following resources for information or assistance: