iCare Family Care Partnership Plan
Complaints, Grievances and Appeals

What are Complaints, Grievances and Appeals?

A complaint or grievance is how a member or member’s authorized representative can share that they are not pleased about:

• iCare services or procedures
• a contracted provider’s services or procedures
• services set up  by iCare or a  provider

iCare treats every complaint as a grievance. This means that we will keep track of member complaints, take your concerns seriously and make sincere efforts to resolve them.

Being unhappy 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.

Appeal: If we make a decision to deny a service or benefit you believe you should receive you can ask us to re-review the decision. You have 60 calendar days from the date of the denial letter to submit a written request for an appeal.

To learn more about complaints, grievances, appeals and other health insurance terms, click:

Health Insurance Terms

 

Appeals

If you are asking to appeal a decision for your Family Care Partnership benefits, an appeal request can be made either orally or in writing. An oral filing must be followed up with a written request. Verbal or written requests must be received within 60 calendar days from the date of the denial letter.

There are three ways in which you can request to appeal a denied service:  local appeal, DHS Review, and or/ Fair Hearing. Please note that you may choose to begin with any of these three options but cannot request a local appeal if the denial has been upheld after a DHS Review or Fair Hearing.

Option 1 - Local Appeals

There are two types of Local Appeals:

1. Standard: Standard appeal decisions are made no later than 30 calendar days from receiving the request for an appeal. Independent Care 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. To make a local appeal, please contact your iCare care manager or member rights specialist. You can also start the process by filling out and sending in this request form: FCP Appeals Request Form

2. 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
Independent Care Health Plan
1555 N. RiverCenter Dr. Ste. 206
Milwaukee, WI 53212-3958

Phone: 414-223-4847
Toll Free: 800-777-4376
TTY: 800-947-3529
Fax: 414-918-7592

 

An iCare Member Rights Specialist can inform you of your rights, attempt to informally resolve your concern, and assist you with filing an appeal. He or she cannot represent you at a State fair hearing. To contact iCare’s Member Rights Specialist:

Member Rights Specialist
Independent Care Health Plan
1555 North 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

 

The following independent ombudsman agencies may be able to provide you with free help. These agencies advocate for Family Care Partnership members.

For members age 18 to 59: Disability Rights Wisconsin Family Care and IRIS Ombudsman Program

Call the office closest to you:

Toll Free Madison: 800-928-8778
Milwaukee: 800-708-3034
Rice Lake: 877-338-3724
TTY (888) 758-6049

For members age 60 and older: Wisconsin Board on Aging and Long Term Care

Toll Free: 800-815-0015

To file an appeal with Medicare directly, please use this link: Medicare Complaint Form

 

What Happens Next?

Step 1: Within 5 business days you will receive a letter confirming your appeal has been received

Step 2: Within 30 calendar days of receiving your appeal iCare will investigate and make all reasonable efforts to gather more info about to your appeal

Step 3: An Appeal Committee meeting is scheduled. Members are encouraged to attend the appeal meeting and speak with the Committee

Step 4: After the Committee reviews all of the information, and speaks to the member, a decision is made to either approve or deny the benefit

Step 5: If the Committee approves the service, iCare will okay the service in dispute

Step 6: If the committee determines to deny the benefit, you can ask the state to review the denial or request a Fair Hearing

 

Option 2 - Department of Health Services Review

You may also choose to have this decision reviewed by MetaStar, the Department of Health Services’ external quality review organization. MetaStar will try to resolve your concerns informally. You can request to have your services continued during the review, if you request the review on or before the effective date of the intended action. If you request a state fair hearing, MetaStar will review your appeal. Please note, however, that MetaStar cannot require any MCO to change its decision.

To request that MetaStar review your case immediately or to learn more about a MetaStar review, call 1-888-203-8338. You may also request a MetaStar review by mail, fax, or email.

DHS Family Care and Partnership Grievances, c/o MetaStar
2909 Landmark Place
Madison, WI 53713
Fax: 608-274-8340
E-mail MetaStar at: dhsfamcare@wisconsin.gov

 

Option 3 - Fair Hearing

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.

To file a request for a fair hearing, you can ask for a hearing and/or a hearing form from the Member Rights Specialist at 414-231-1076. You can also request a hearing form from one of the independent ombudsman agencies listed or you can go online and get a form at:

REQUEST FOR A STATE FAIR HEARING

You can send the completed request form or a letter asking for a hearing and a copy of this notice to:

Family Care Request for Fair Hearing, c/o Wisconsin Division of Hearings and Appeals

5005 University Ave. #201

Madison, WI 53705-5400

or

Fax: 608-264-9885

​​​​​​H2237_IC2203_M   DHS approved 07/18/19
Last Updated 07/18/19