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iCare Medicare Part C
Complaints, Grievances and Appeals

iCare Medicare Part C Complaints, Grievances and Appeals

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What is a Grievance?

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). Independent Care Health Plan 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 Quality Improvement department will conduct an investigation. At the conclusion of the investigation, you will receive a letter explaining how iCare resolved your grievance.

If you want your grievance to be in writing (this is not required for standard grievances), please send it to:

Independent Care Health Plan

Attention: Member Grievances

1555 N. RiverCenter Dr., Suite 206

Milwaukee, WI 53212

OR

Fax: 414-918-7592

If you want a fast (expedited) decision about your grievance, you must ask for it in writing. iCare will resolve expedited grievances within 3 business days. If iCare decide that your condition does not require a fast (expedited) decision, iCare will notify you in writing that it has been transferred to the standard time frame. You have the right to appeal a determination that iCare makes denying a fast (expedited) decision.

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, please call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529).

 

Ombudsman

The Medicare Ombudsman is also available to assist you with complains, grievances, and information requests.

You can also contact iCare’s Member Advocate/Member Rights Specialist at 414-231-1076 for assistance.

 

Medicare Complaint Form

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using the form found at www.medicare.gov/MedicareComplaintForm/home.aspx.

 

Medicare Part C Appeals

Appeal: 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. You have 60 calendar days from the date of the denial letter to submit a written request for 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 your life is not in serious jeopardy. iCare will decide whether the appeal qualifies as expedited within 2 business days. If the request for a fast appeal is denied, you will be notified in writing of your right to file an expedited grievance.

If iCare agrees that your appeal should be expedited, it will follow the same steps as a standard appeal. The appeal process will be completed within 72 hours from receiving the appeal request.

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

Quality Improvement Department

Attention: Member Appeals

Independent Care Health Plan

1555 N. RiverCenter Dr. Ste. 206

Milwaukee, WI 53212-3958

Fax: 414-918-7592

 

What Happens Next?

  • Step 1: Within 5 business days you will receive an acknowledgment letter confirming that iCare has received your appeal
  • Step 2: Within 30 calendar days of receiving your appeal, iCare will investigate and make all reasonable efforts to gather additional information relevant to your appeal
  • Step 3: After gathering any additional information, iCare will obtain a review by a third party that was not previously involved in the decision process
  • Step 4: If the third party review determines iCare made an incorrect decision, iCare will authorize the service in dispute
  • Step 5: If the third party review determines iCare made the correct decision, the appeal file is forwarded to an independent reviewer hired by Medicare to make a final decision

You will receive written notification of the final decision.

If you need assistance filing an appeal, contact iCare's Quality Improvement Department at 414-918-7565 or a Member Advocate at 414-231-1076

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Last Updated 10/1/19

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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