Grievance and appeals

Contact

At times you may have questions and concerns about benefits, claims or services you receive from Dean Health Plan. Sharing your concerns will help us to identify our strengths and weaknesses.

When a question or concern arises, we encourage you to reach out to our Customer Care Center at 800-279-1301. Our Customer Care Specialists will make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care.

Grievance/Appeal

A grievance/appeal is any dissatisfaction with Us, including adverse determinations, the way We provide services or process claims, a decision to change or rescind a policy or a decision to deny a benefit. A grievance/appeal  must be expressed in writing to Us by, or on behalf of, a Member.

If you wish to receive a free copy of any documents relevant to the outcome of your grievance/appeal, send a written request to the address listed below. All standard grievances/appeals will be resolved within 30 calendar days of the day We receive your request. All expedited grievances/appeals will be resolved within 72 hours of the time We receive your request.

This grievance/appeal process does not apply when a Member is requesting coverage of a Drug or item not listed on Our formulary. These requests are subject to the non-formulary exception process described later in this section.

To file a grievance/appeal, you or your authorized representative must send your grievance/appeal to Us in writing at the following address:

Dean Health Plan, Inc.
Attention: Grievance and Appeal Department
P.O. Box 56099 Madison, WI 53705

When We receive your grievance/appeal, Our Grievance and Appeal Department will send you an acknowledgement letter within 5 business days. Our acknowledgment letter will advise you of:

  • Your right to submit written comments, documents or other information regarding your grievance/appeal;
  • Your right to be assisted or represented by another person of your choosing;
  • Your right to appear before the Grievance and Appeal Committee; and
  • The date and time of the next scheduled Grievance and Appeal Committee meeting. This meeting will not be less than 7 calendar days from the date of your acknowledgment letter but will occur within 30 calendar days of the date We received your grievance/appeal.


If you choose to meet with the Grievance and Appeal Committee you may do so either in person or over the phone via teleconference. As described in the acknowledgement letter you must call and schedule a meeting time.

Your grievance/appeal will be documented and investigated. So that you will have time to respond prior to Our decision, We will automatically send you the following information:

  1. Any new or additional evidence We consider, rely upon, or generate in the course of considering your grievance/appeal; or
  2. Any new or additional rationale We use to make Our decision.

 

Expedited Grievance/Appeal

If We decide your grievance/appeal is urgent according to Our criteria, We will resolve your request within 72 hours of the time We receive it. Our criteria are based on the expedited grievance/appeal provisions of applicable law. For situations involving Ongoing Course of Treatment and/or concurrent review, coverage will continue during the grievance/appeal process.

We will automatically treat your grievance/appeal as expedited if:

  1. Your concerns are related to a facility admission or concurrent review of a continued facility stay;
  2. Our Medical Director decides your life, health, or ability to regain maximum function could be jeopardized by the standard review timeframe;
  3. Your health care provider notifies Us that you would be subject to severe pain that cannot be adequately managed without the services you requested; or
  4. Your health care provider notifies Us that he or she has decided you need care urgently.


You, your authorized representative or your health care provider may request an expedited grievance/appeal either orally or in writing. You can make this request in your initial request or in a separate communication.

If you are eligible for an expedited internal grievance/appeal and also for external review, you can request that your internal and external reviews happen at the same time.

Independent external review

You may also be entitled to an independent external review. You can ask for an external review if We denied your grievance/appeal and it involves care that We have determined does not meet the Policy requirements for reasons involving medical judgement. Those reasons include, but are not limited to:

  1. Medical Necessity;
  2. Appropriateness;
  3. Health care setting;
  4. Level of care; or
  5. Effectiveness of a covered benefit.


You can also request an external review if your requested services are considered Experimental or Investigational or if We have rescinded your Policy, whether You or a Qualified Dependent is entitled to a reasonable alternative standard for a reward under a wellness program, or whether We are complying with the non-quantitative treatment limitation provisions of mental health parity requirements.

You must exhaust Our internal review process before you can request an external review unless:

  1. We fail to comply with internal claims and appeals requirements;
  2. You request an expedited external review when you request an expedited internal review; or
  3. We grant your request to bypass Our internal review process.


If you or your authorized representative wishes to request an external review, you or your authorized representative must submit your request within four months of the date We decided your grievance/appeal.

There are two categories of external review, standard and expedited. Most requests for external review will follow the standard timeline; however in some cases you may ask for an expedited (faster) review.

STANDARD EXTERNAL REVIEW

You may request a standard external review in one of the following ways:

1. By directly submitting the request online at externalappeal.cms.gov;
2. By mailing the request to the independent review organization (IRO) at the following address:


MAXIMUS Federal Services
3750 Monroe Avenue, Suite 705
Pittsford, NY 14534

3. By faxing the request to (888)-866-6190.

If you choose to mail or fax your request, print and fill out the online form. Please note you may also provide additional documentation such as:

  1. Documents to support the claim, such as letters from your health care provider, reports, bills, medical records, explanation of benefits (EOB) forms (optional);
  2. Letters sent to your health insurance plan about the denied claim (optional); and
  3. Letters received from the health insurance plan (optional).


You can get the online form at externalappeal.cms.gov or by calling our Customer Care Center at 800-279-1301 (TTY: 711).

The IRO will notify you and Us of its decision no later than 45 days after it receives your request for external review.

A decision made by the IRO is binding for both you (the Member) and Us with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the IER.

EXPEDITED EXTERNAL REVIEW

In some cases you may ask for an expedited (faster than usual) external review. You may request an expedited external review when:

1. You have asked for an expedited grievance/appeal and want an expedited external review concurrently (at the same time) and the timeframe for an expedited grievance/appeal (72 hours) would place your life, health, or ability to regain maximum function in danger; or

2. You have completed the internal grievance/appeal process described above and the decision was not in your favor, and:
a The timeframe to do a standard external review (45 days) would place your life, health or ability to regain maximum function in danger; or
b. The decision is about admission, care availability, continued stay, or emergency health care services where the person has not been discharged from the facility.


You may request an expedited external review by following the process described above for standard external reviews, or by calling the IRO at (888) 866-6205. The 72-hour timeframe for an expedited review request begins when the phone call ends.

The IRO will notify you and Us of its decision as soon as possible, but no later than 72 hours after it receives your request for external review. The IRO may call you with its decision, but it must also mail you a written version of the decision within 48 hours of calling you.

A decision made by the IRO is binding for both Us and the Member with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the IER.

Office of the Commissioner of Insurance

You may resolve your problem by taking the steps outlined above. You may also contact the Office of the Commissioner of Insurance, a state agency which enforces Wisconsin’s insurance laws and file a complaint.

You may file a complaint online or print a complaint form at: oci.wi.gov/.

You may also request a complaint form by writing to:

Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873

Or calling (608) 266-0103 (Madison) or toll free at 1-800-236-8517 (Statewide).

Non-formulary exception to coverage

If you or your prescribing health care provider wish to request review of a denied non-formulary exception to coverage request you may do so in writing or orally.

Our timeline for considering your exception to coverage will vary based on the urgency of your situation.

STANDARD NON-FORMULARY EXCEPTION

If your request is not urgent We will follow Our standard non-formulary exception timeline.

We will notify you, your authorized representative and your prescribing health care provider of our decision no later than 72 hours after We receive your request. During the exception to coverage process, We will cover the drug for the duration of the prescription during a standard exception request. If We approve your request, We will cover the Drug until your prescription expires, including refills.

If We deny your standard non-formulary exception , you, your authorized representative, or your prescribing health care provider may ask to have Our denial reviewed by the IRO. You must ask for external review within four months of Our denial. You may submit to Us in writing at the following address:

Dean Health Plan, Inc.
Attention: Grievance and Appeal Department
P.O. Box 56099 Madison, WI 53705

You or your authorized representative must select an IRO from the list of IROs certified by the Office of the Commissioner of Insurance. In addition, your written request must contain the name of the IRO selected. The selected IRO will send you a notice of acceptance within one business day of receipt, advising you of the right to submit additional information. The selected IRO will also deliver a notice of the final external review decision in writing to you and Us within the timeline required based on Wisconsin State Law. A decision made by an IRO is binding for both Us and the Member with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the IER.

EXPEDITED NON-FORMULARY EXCEPTION

If you need the requested Drug more urgently, and We determine your request meets Our expedited criteria We will follow Our expedited non-formulary request timeline. Our criteria are based on the expedited provisions of applicable law as listed below:

Urgent circumstances exist

  1. When you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain function, or
  2. You are undergoing a current course of treatment using a non- formulary Drug. When you submit your request, you must indicate that your circumstances are urgent.


We will notify you or your authorized representative and your prescribing health care provider of our decision no later than 24 hours after We receive your request. During the exception to coverage process, We will cover the Drug for the duration of the exigency during an expedited exception request. If We approve your request, We will cover the Drug until your prescription expires, including refills.

If We deny your expedited non- formulary exception request, you, your authorized representative, or your prescribing health care provider may ask to have Our denial reviewed by the IRO. You must ask for external review within four months of Our denial. You may submit orally by calling (608) 828-1991 or TTY 711, or submit to Us in writing at the following address:

Dean Health Plan, Inc.
Attention: Grievance and Appeal Department
P.O. Box 56099
Madison, WI 53705

You or your authorized representative must select an IRO from the list of IROs certified by the Office of the Commissioner of Insurance. In addition, your written request must contain the name of the IRO selected. The selected IRO will send you a notice of acceptance within one business day of receipt, advising you of the right to submit additional information. The selected IRO will also deliver a notice of the final external review decision in writing to you and Us within the timeline required based on Wisconsin State Law. A decision made by an IRO is binding for both Us and the Member with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the IER.