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Medicaid SSI & BadgerCare Plus Grievances

 

A grievance is any complaint about your HMO or health care provider that is not an adverse benefit determination (see “Appeals” below for more information about adverse benefit determinations).

Grievance topics include:

  • iCare services or procedures
  • a contracted provider’s services or procedures
  • services arranged by iCare or a contracted provider
  • not respecting your rights as a member
  • inability to obtain culturally and linguistically appropriate services and responsive care

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).

If you are enrolled in a Medicaid SSI program and you want to talk to someone outside iCare about the problem, you can contact SSI Managed Care External Advocacy Project at 1-800-928-8778. Medicaid SSI and BadgerCare Plus members can also contact the BadgerCare Plus and Medicaid Ombuds at 1-800-760-0001. The Ombuds may be able to help you solve the problem or write a formal grievance to iCare or to the Medicaid program. The address to file a grievance with the Medicaid program is below.

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

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

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 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:

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:

IC318 DHS Approved for use on 2/5/2022
Last Updated 2/8/2022

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