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iCare Family Care Partnership Plan
Complaints, Grievances and Appeals

iCare Family Care Partnership Plan Complaints, Grievances and Appeals

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Grievances

 

A grievance is when you or your representative are not satisfied with:

  • iCare services or procedures
  • a  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.

Not agreeing with a determination of coverage is not considered a grievance but may be treated as an appeal. It is up to iCare to decide 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  may call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529). iCare accepts both oral and written grievances.  iCare will try to solve any complaint that you might have over the phone. iCare will let you know in writing within 5 business days that your grievance has been received. If iCare cannot solve your complaint over the phone, the iCare Grievance and Appeal Coordinator will look into it. If the grievance cannot be resolved informally, members have a right to be heard before the iCare Grievance and Appeal Committee. Members also have the option to be represented by an advocate, peer or representative during the grievance process. A member representative is also part of the Committee, but this can be waived by a member. 

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 let you know of our decision about your grievance as quickly as your case requires. This is based on your health status, but no later than 90 calendar days after receiving your complaint. iCare may extend the time frame by up to 14 calendar days if you request the extension, or if iCare is able to justify a need for more info and the delay is in your best interest. At the end of the grievance process, you will receive a letter. It will explain how iCare resolved your grievance.

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.

You can ask about the status of a grievance you filed with iCare.  Please call Customer Service at 1-800-777-4376 (TTY 1-800-947-3529).

 

State Review of Your Grievance


If you are not pleased with how iCare has resolved your grievance, or if we do not respond to your grievance within 90 days (or 14 additional days if there was an extension), you can file a grievance with the State. The State contracts with MetaStar, an external Quality Review Organization, to complete this review.  MetaStar would then make the final decision on your grievance.

Your request for a State review of your grievance must be postmarked, faxed, or e-mailed to MetaStar no later than 45 calendar days from the date of our decision letter regarding your grievance, or the date we should have responded to your grievance if you did not receive a response.  To ask MetaStar to review your grievance, call 1-888-203-8338.  You may also ask for review by mail, fax, or e-mail:

DHS Family Care Grievances
MetaStar
2909 Landmark Place
Madison, WI 53713
Fax: 608-274-8340
Email:dhsfamcare@dhs.wisconsin.gov

 

If you are have Medicare and want to file a complaint with Medicare directly, please use this link: Medicare Complaint Form.

 

Appeals

If iCare decides to deny a service or benefit you believe you should receive, you can ask iCare to reconsider. This is called an appeal.  You have 60 calendar days from the date of the denial letter from iCare to send an appeal.  You can request an appeal orally, but you must follow up your oral appeal request with a written request for an appeal.  If you want your benefits to continue while your appeal is pending, you must file your appeal and ask that your benefits continue within 10 days of the date of our denial letter or before the effective date of the change in benefits, whichever is later.

Members have a right to be heard before the iCare Grievance and Appeal Committee. Members also may choose to be represented by an advocate, peer or representative during the appeal process. A member representative is also part of the Committee, but this can be waived by a member.  You have a right to receive a copy of all papers, records and other info relied on by iCare related to your appeal. This is free of charge.

You cannot request a State Fair Hearing until you have used up all of your appeal rights with iCare.  If iCare does not make a decision on your appeal within the time frames below, you are deemed to have used up 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 getting the written request for an appeal. iCare may extend the time frame by up to 14 calendar days if you request the extension, or if iCare is able to justify a need for more info and the delay is in your best interest.

Expedited (Fast) Appeal: You can ask for a fast appeal if you feel your life or health could be in danger by waiting the standard time. Fast appeals can be changed to the standard time frame if it is deemed your life or health is not in serious danger. iCare will decide whether the appeal should be fast within 2 business days. If the request for a fast appeal is denied, we will let you know in writing of your right to file a grievance. 

If iCare agrees that your appeal should be fast, 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 more time, or if iCare is able to justify a need for more info and the delay is in your best interest.

Appeals must be sent 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
Fax:  414-918-7589

 

What Happens Next

 

Within 5 business days you will receive a 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 and you will get a letter of our decision.  If we determine we made a wrong decision, iCare will approve 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 used all options in 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
Fax: 608-264-9885

 

You need to ask for a Fair Hearing within 90 days of the date of iCare’s written decision to you on your appeal with iCare. 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.

 

If You Also Have Medicare

 

If you are an iCare Family Care Partnership Member and also have Medicare benefits with iCare, and you are grieving or appealing a benefit covered by Medicare, please see the Medicare grievance and appeal information on this website for further information.

 

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

The iCare Family Care Partnership program has a Member Rights Specialist 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 Rights Specialist
Independent Care Health Plan
1555 N. RiverCenter Drive, 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

 

Anyone receiving Family Care, Family Care Partnership, or PACE (Program of All-Inclusive Care for the Elderly) services can get free help from an independent ombudsman. The following agencies advocate for Family Care, Family Care Partnership, and PACE members:

For members age 18 to 59:
Disability Rights Wisconsin
Toll Free: 800-928-8778
TTY: 711

For members age 60 and older:
Wisconsin Board on Aging and Long Term Care
Toll Free: 800-815-0015
TTY: 711

 

For more information on grievances, appeals and other health insurance-related words, visit our health insurance terms and definitions page.

Have Questions?

Call 1-800-777-4376 (TTY: 1-800-947-3529), 24 hours a day, 7 days a week and ask for your Care Manager.

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

​​​​​​H2237_IC2203_M   DHS approved 10/12/20
Last Updated 10/12/20

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