IF YOU ARE A PARTNERSHIP MEMBER AND HAVE BOTH MEDICAID AND MEDICARE:
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.
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. For more information on grievances and appeals, please see Chapter 8 of the Evidence of Coverage.
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 grievance 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 grievance over the phone, the iCare Grievance and Appeal Coordinator will look into it. If the grievance cannot be resolved informally, you have the right to be heard before the iCare Grievance and Appeal Committee. You 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 at your request.
If you want to submit your grievance 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
Note: If your grievance is about the quality of your care, you can file a grievance with the quality improvement organization (QIO) in addition to, or instead of, filing a grievance with iCare.
iCare must let you know of our decision about your grievance as quickly as your case requires based on your health status, but no later than 30 calendar days from the date we receive your grievance; for an expedited (fast) grievance, we must respond within 24 hours.. 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 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 grievance. 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 us at 1-800-777-4376 (TTY 1-800-947-3529).
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 30 days for a standard grievance/24 hours for an expedited grievance (or 14 additional days if there was an extension), you can ask the State to review your grievance. The State contracts with MetaStar, an outside quality group, 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
Note: If your grievance was about the quality of your care, you can also ask the quality improvement organization to review iCare’s decision about your grievance.
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 on the denial letter from iCare to send an appeal. You can request an appeal orally or in writing. If you fail to ask iCare for an appeal within the 60 day deadline but have a “good cause” reason for missing the deadline, iCare may extend this deadline. If the 60 day deadline has expired and you wish to ask iCare to extend the deadline, you must ask iCare to extend the deadline in writing and explain why your appeal was not filed on time. 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.
You have the right to be heard before the iCare Grievance and Appeal Committee. You 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 at your request. You have the right to receive a copy of all papers, records and other information used by iCare related to your appeal. This is free of charge.
You cannot pursue outside review of our decision 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 exhausted iCare’s appeal process and you can proceed to requesting a State Fair Hearing (for services covered by Medicaid), pursuing the Medicare Independent Review Entity (for services covered by Medicare), or both (for services covered by both Medicaid and Medicare).
Appeals Timelines:
- Standard Appeal: iCare makes standard appeal decisions no later than 30 calendar days from the date of receipt of an appeal. iCare may extend the time frame 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.
- 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 added 14 days if there has been an extension), iCare will make a decision about your appeal and you will receive 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 outside review of our decision. If the service requested was covered by Medicaid, you can ask for a State Fair Hearing. All appeals of Medicare-covered services that are either partially favorable, or denied, are automatically forwarded to Medicare’s Independent Review Entity (IRE) for review. If both Medicaid and Medicare cover the service you requested, you can choose to pursue both a State Fair Hearing and Medicare review.
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
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 Administrative Law 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.
Medicare Independent Review Entity Process
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 Partnership services can get free help from an independent ombudsman. The following agencies advocate for Family Care Partnership 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.