Members

2012 iCare Family Care Partnership
Appeals and Grievance Overview

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This overview is a general description of our Appeals and Grievance Process for members of iCare Family Care Partnership (HMO SNP). Be mindful that it does not provide a detailed explanation of the Appeals and Grievance Process. To receive a complete description of our Appeals and Grievance Process, please call iCare Family Care Partnership (HMO SNP) and ask for the Evidence of Coverage (EOC)/Member Handbook, or click the link above and go to Chapter 9 of your EOC/Member Handbook. To obtain an aggregate number of grievance, appeals and exceptions filed with iCare, contact us at 1-800-777-4376 (TTY: 1-800-947-3529).

Coverage Determination (Exception), Appeal and Grievance Process

Most problems can be solved by your Partnership Team. If you have a problem, we encourage you to first call your Team at 1-414-223-4847 or 1-800-777-4376 (TTY: 1-800-947-3529). We will try to resolve any problem that you might have over the phone. If the problem is not solved following your discussion with the Team, you have the right to make a complaint if you have concerns or problems related to your coverage or care.

If your Team is unable to help you, contact the iCare Family Care Partnership (HMO SNP) Member Rights Specialist:

Appeals and grievances are the two different types of complaints you can make. The process varies slightly depending on whether it is a Medicare, Medicaid or a Medicare Part D Prescription Drug grievance or appeal. If you are not sure how to proceed, your Partnership Team or the Member Rights Specialist can help you to assess how to proceed.

Appeals

An appeal is a type of complaint a member makes when they want Partnership to reconsider or change a decision we have already made, examples:

• Denial or limited authorization of a requested service
• Denial of a drug
• Reduction, suspension or termination of a previously authorized service, unless you agree to the change
• Denial, in whole or part, of payment for a service
• Failure of Partnership to act within the timeframe provided
• Failure to provide services and support items in a timely manner

The development of an individualized service plan that is unacceptable because the plan requires the member to live in a place that is unacceptable to the member; the plan does not provide sufficient care, treatment or support to meet the member’s needs and identified outcomes; the plan requires the member to accept care, treatment or support items that are unnecessarily restrictive or unwanted by the member

• Notification of a decision made in response to a member's grievance
• Loss of eligibility for Medicaid

You or someone you name to act for you (your appointed representative) may request an appeal. You can name a relative, friend, advocate, attorney, doctor, or someone else to act for you. Others 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) and include it with your written statement that gives the person legal permission to act as your appointed representative. This statement must be sent to us at:

Print this form to appoint your representative:

CMS Appointment of Representative Form (CMS-1696)

If you wish to file an APPEAL, a PRESCRIPTION DRUG APPEAL or request a COVERAGE DETERMINATION we encourage you to initially contact your Team at 1-414-223-4847 or 1-800-777-4376 (TTY: 1-800-947-3529). All appeals may be submitted orally or in writing to the following:

• Telephone: 1-414-223-4847 or 1-800-777-4376 (TTY: 1-800-947-3529), 24 hours-a-day, seven days-a-week.
• Facsimile: 414-231-1092
• Independent Care Health Plan
  1555 N. RiverCenter Dr., Suite 206
  Milwaukee, WI 53212

You may print this form and send to iCare at the address indicated above:

Redetermination Request Form

Or, you may click here to submit an appeal request through our secure web form.

If you wish to file an EXPEDITED APPEAL to appeal a decision our plan made about coverage for care or a prescription drug you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal,” because the standard resolution timeframe could seriously jeopardize your life, health or ability to attain, maintain or regain maximum function. All appeals may be submitted orally or in writing as described above.

GRIEVANCES

A grievance is a type of complaint that a member can make about Partnership or one of our plan providers. This type of complaint does not involve payment or coverage disputes, examples:

• Quality of services
• Office waiting times
• Behavior of service providers
• Adequacy of facilities
• Access to providers and/or services
• Refusal to expedite an organization determination or reconsideration

GRIEVANCE AND APPEAL COMMITTEE

Partnership has a grievance and appeal committee whose primary purpose is to resolve any formal grievance or appeal at the plan level. A few of the pieces involved in this process are:

• Staff may be asked for information pertinent to a formal grievance or appeal
• Grievances and appeals are maintained in a confidential manner
• Members are free from discrimination or retaliation when they exercise their right to file a grievance or appeal
• Members or authorized representatives determine if they want to initiate the grievance and appeal process

COVERAGE DETERMINATION

When the Partnership Program makes a coverage determination, we are making a decision whether or not to provide or pay for a service or drug, as well as what services or drugs are covered for you and what we will pay for those services or drugs. Coverage determinations include exceptions requests. You have the right to ask us for an “exception” if you believe you need a drug that is not on our formulary or believe you should get a drug at a lower co-payment (if you have Medicare).

Coverage Determination (Exception) - All members can request a coverage determination, including a request for a tiering or formulary exception if you have Medicare. A request can also be made on your behalf by your appointed representative or your prescribing physician.

A request for a standard coverage determination can be made orally or in writing. A request for an Expedited Coverage Determination can be made orally or in writing. You, your appointed representative, or your prescribing physician may submit a written request for a coverage determination in any format.

To request a Part D coverage determination:

• Call us at 1-414-223-4847 or 1-800-777-4376 (TTY: 1-866-706-4757), 24 hours-a-day, seven days-a-week, or;
• 1-800-910-4743, 24 hours-a-day for Medicare Part D Requests, and;
• 1-800-788-2949, 24 hours-a-day for Medicaid Requests
• Facsimile: 1-858-790-7100
• MedImpact Healthcare Systems
  Attn: Prior Authorization Dept.
  10680 Treena St., Stop 5
  San Diego, CA 92131

You may print this form and send it to the address or fax listed at the top of the form:

Coverage Determination Request Form

Or, you may click here to submit a coverage determination request through the web. You will be redirected to the website of our Pharmacy Benefits Manager.

Review by the State of Wisconsin Department of Health Services - Medicaid Appeals

You can also request a review by the State of Wisconsin Department of Health Services. Your review request must be submitted within 45 days after iCare Family Care Partnership (HMO SNP) initial decision or our decision in response to your appeal. These review requests should be submitted through MetaStar, Inc. at the address below. MetaStar can also help you write your review request.

Filing your appeal with the State Division of Hearings and Appeals

You can also appeal directly to the State of Wisconsin Department of Administration Division of Hearing and Appeals to request a State fair hearing for Medicaid appeals. Your appeal must be submitted within 45 days after iCare Family Care Partnership (HMO SNP) initial decision or iCare Family Care Partnership (HMO SNP) decision in response to your appeal or the Department’s decision to your appeal. If you want a hearing before the State Division of Hearings and Appeals, you must request one in writing. iCare’s Member Rights Specialist can assist you in writing the appeal. Please send your request to:

Ombudsman Assistance

The Wisconsin Department of Health Services has arrangements with Disability Rights Wisconsin and the Wisconsin Board on Aging and Long Term Care to offer ombudsman programs free of charge.

Regional ombudsmen will assist current or potential Partnership members and their families or guardians with ensuring quantity and quality of services; complaint investigation; mediation and resolution of conflicts; provision of information and education on current and potential members’ rights and benefits; and preparation for and representation at appeals, grievances and fair hearings.

You can contact:

Disability Rights Wisconsin—Ombudsmen from this agency provide advocacy to individuals under age 60.

Wisconsin Board on Aging and Long Term Care—Ombudsmen from this agency provide advocacy to individuals age 60 and older.

Contact Us

Questions? Call us at 1-800-777-4376 (TTY 1-800-947-3529), 7 days-a-week, 8:00 a.m. to 8:00 p.m. Our mailing and walk-in address is: Independent Care Health Plan, 1555 N. RiverCenter Dr., Suite 206, Milwaukee, WI 53212.

Last Updated: 12/09/2011

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