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Complaints, Grievances and Appeals

iCare Medicare Part C Complaints, Grievances and Appeals

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Medicare 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

iCare 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 complaint, you must file your grievance within 60 days of the date of the incident that you are complaining about.  iCare accepts both oral and written grievances. You are encouraged to call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529) to report your grievance. 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 Drive, 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 filed with iCare, please call Customer Service at 1-800-777-4376 (TTY: 1-800-947-3529).

Medicare Complaint Form

You may also submit feedback or a complaint about your Medicare health plan or prescription drug plan directly to Medicare using the form found at this link:  Medicare Complaint Form.

Who May Ask For a Grievance or Appeal 

You can file a grievance or appeal yourself, your treating physician can file one for you, or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, 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 CMS Appointment of Representative form (CMS-1696) or an equivalent document and include it with your request for a grievance or appeal. This will give the person you name legal permission to act as your appointed representative. This form must be sent to us at:

Independent Care Health Plan
Attn: Grievance and Appeals Coordinator
1555 N. RiverCenter Dr., Suite 206
Milwaukee, WI 53212

OR 

Fax: 414-918-7589

You can print this form to appoint your representative:

CMS Appointment of Representative form (CMS-1696)

You also have the right to have an attorney file a grievance or appeal on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.

Medicare Appeals

If iCare makes a decision to deny a service or benefit you believe you are entitled to receive, you can ask iCare to reconsider the decision.  This is called an appeal.  iCare accepts oral and written appeals. You have 60 calendar days from the date of the denial letter from iCare to request an appeal.

Two Types of Appeals:

Standard: Independent Care Health Plan makes standard appeal decisions no later than 30 calendar days from receiving the written request for an appeal. iCare may extend the timeframe up to 14 calendar days if you request the extension or if iCare is able to justify that an extension is in your best interest.

Expedited (fast) Appeal: You can ask for an expedited appeal if you feel your health could be in jeopardy by waiting the standard timeframe. Expedited appeals can be transferred to the standard timeframe if it is determined that 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 an expedited grievance.  iCare will resolve expedited grievances within 24 hours.

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 Drive, Suite 206
Milwaukee, WI 53212-3958

OR

Fax: 414-918-7589

 

What Happens Next

Within 10 business days you will receive an acknowledgment letter confirming that iCare has received your appeal.

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.  If we determine we made an incorrect decision, iCare will authorize the services.  If we determine we were correct to deny your services, your appeal will be automatically forwarded to an independent reviewer hired by Medicare to make a final decision.

You will receive written notification of the final decision from the independent reviewer.

How to Obtain an Aggregate Number of Grievances, Appeals and Exceptions Filed

To obtain an aggregate number of grievances, appeals and exceptions filed with iCare, please call Customer Service at 1-800-777-4376.

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 Drive, Suite 206
Milwaukee, WI 53212

Phone: 1-414-231-1076
Toll Free: 800-777-4376
TTY: 800-947-3529
Fax: 414-231-1090
E-mail: advocate@iCareHealthPlan.org

 

The Medicare Ombudsman is also available to assist you with complaints, grievances, and information requests. You can obtain information about the Ombudsman here:  http://www.longtermcare.wi.gov/

 

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

​​​​​​H2237_IC2203_M DHS approved 4/9/20
Last Updated 9/28/20

Have Questions?

Call 1-800-777-4376 (TTY: 1-800-947-3529), 24 hours a day, 7 days a week.

Our office hours are Monday – Friday, 8:30 a.m. – 5:00 p.m.

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By clicking this link, you may be leaving the iCareHealthPlan.org website. Independent Care Health Plan (iCare) only provides these links and pointers for your information and convenience. When you select a link to an outside website, you are leaving the www.iCareHealthPlan.org website.

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