As your insurance partner, we’re here to help you navigate through the healthcare system when you need it most. We have everything you need in this section to manage your health coverage online and we’re also happy to take your calls or emails when you have questions.
Your Member Benefits
As a Dean Health Plan member, you received information on to access your member materials on our website which include your benefit information. These documents together specifically outline the benefits, services, exclusions, and limitations under your Dean Health Plan policy. The same Member Certificate is issued for many different plans, but the Schedule of Benefits reflects your plan's specific benefits. It is possible that a benefit described in the Member Certificate may not apply to your particular plan. This would then be shown in your Schedule of Benefits. You should consult the Schedule of Benefits to determine whether and to what extent a service is covered under your specific plan. It is important to always look at both the Member Certificate and Schedule of Benefits to determine benefits covered under your plan.
Each year as your policy renews, you will receive information on any policy changes or clarifications. Please be sure to read all information carefully so that you may fully utilize your coverage and be familiar with your benefits. When you understand the extent of your health care coverage, you can make the most of your health care benefits.
Time is a valuable commodity for all of us; that is why Dean Health Plan minimizes the amount of paperwork required for our members. In most cases, claims are submitted directly to Dean Health Plan by the providers or clinics. On occasion, it may be necessary for you to submit a claim for reimbursement. When submitting the claim be sure to follow these guidelines:
- Send an itemized bill from the provider of service. If services were received outside of the United States, you will need to submit the original bill along with an itemized bill that has been translated into English and indicate the appropriate currency exchange rate at the time the services were received.
- Send the bill within 60 days after the services are received to Dean Health Plan, Attn: Claims Department, P.O. Box 56099, Madison, WI 53705.
- If you have another insurance company that is primary payer, you will have to send the Explanation of Benefits (described below) to Dean Health Plan or your health care provider.
Explanation of Benefits (EOB)
Occasionally, you may be responsible for paying a portion of a claim. The most common financial responsibilities of our members involve deductible, coinsurance, copayment amounts or charges from non-plan providers. You will be notified of financial responsibilities other than fixed dollar amounts with a form called an "Explanation of Benefits".
The EOB contains important information including the total amount charged, the amount paid by Dean Health Plan, and the amount that is the member's responsibility.
An EOB is not a bill. The dollar amount indicated as member responsibility on your EOB should always be paid to the provider of service upon receipt of a bill, and not to Dean Health Plan.
Member Rights and Responsibilities
Dean Health Plan, Inc. (DHP) members deserve the best service and health care possible. DHP is committed to maintaining a mutually respectful relationship with its members. To promote effective health care, DHP makes clear its expectations for the rights and responsibilities of its members, to foster cooperation among members, practitioners and DHP. The Member Rights and Responsibilities, outlined below, also appear annually in our Dean Health Plan member newsletter, Notables.
DHP members have the right to:
Be treated with respect and recognition of their dignity and right to privacy.
Receive a listing of DHP participating practitioners in order to choose a Primary Care Physician.
Present a question or complaint or grievance to DHP, about the organization or the care it provides, without fear of discrimination or repercussion.
Receive information on procedures and policies regarding their health care benefits.
Timely responses to requests regarding their health care plan.
Request information regarding Advance Directives.
Participate with practitioners in making decisions about their health care.
A candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
Receive information about the organization, its services, its practitioners and providers, and members' rights and responsibilities.
Make recommendations regarding the organization's members' rights and responsibilities policies.
DHP members have the responsibility to:
Read and understand the materials provided by DHP concerning their health care benefits. DHP encourages members to contact the Plan if they have any questions.
Present their ID Card in order to identify themselves as DHP members before receiving health care services.
Notify DHP of any enrollment status changes such as family size or address.
Supply information (to the extent possible) that the organization and its practitioners and providers need in order to provide care.
Follow plans and instructions for care that they have agreed on with their practitioners.
Understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
Fulfill financial obligations as it relates to any copays, deductibles and/or premiums as outlined in your policy.
Copayments, Deductible and Co-insurances
Some Dean Health Plan policies may contain a co-payment, a deductible, and/or co-insurance for covered services. As a member you are responsible for these amounts, so it is important to understand the differences of each and how they affect your policy.
A copayment is a specified dollar amount or a percentage that you must pay each time covered services are provided. Some examples of services that may have a copayment are: office visits, emergency room visits, prescription drugs. As a member you should be prepared to pay your copayment at the time of services. Please refer to your Schedule of Benefits for your plan's specific copayment information.
A deductible is a specified dollar amount that a member or family is required to pay each contract year before Dean Health Plan will pay for covered services. Your deductible is indicated in your Schedule of Benefits and is calculated according to your plan's contract year. When a member or family satisfies the deductible during the plan's benefit year, services will be covered at the percentage (co-insurance) indicated in your Schedule of Benefits. Unless otherwise indicated, the deductible must be met before the policy begins paying for services.
Co-insurance is a specified percentage that you must pay when covered services are provided. The co-insurance amount paid by you is normally applied toward the out of pocket maximum as indicated in your Schedule of Benefits.
An out of pocket maximum is an accumulated dollar amount that you pay for covered services during the plan's benefit year. The out of pocket maximum is normally the accumulated costs of covered services that you have paid for deductible and co-insurance as indicated in your Schedule of Benefits. Once you have reached your out of pocket maximum, covered services are available at 100% for the remainder of the benefit year. Copayments, non-covered services, and benefit reduction amounts do not apply to the out of pocket maximum.
If you, as a member, are responsible for any portion of the cost for covered health care benefits that you receive, Dean Health Plan will send you an Explanation of Benefits.
How Claims are Processed
If you are a member of the State of Wisconsin, Wisconsin Public Employer Group plans or GM Employer Group plan, please disregard this section.
When you receive services from any plan providers, the charges are covered based on the contract agreements Dean Health Plan has with all of our plan providers. If there is a difference between the billed amount and what Dean Health Plan allows, you will not be held liable for that amount. You will only be liable for any copayments, deductible or coinsurances of your policy or any non-covered services.
When you receive services from non-plan providers, the situation is different. Because we do not have any contract agreements with non-plan providers, the charges that are covered are based on our maximum allowable fee.
The maximum amount we allow varies by the type of provider you see and the type of services you receive. If there is any difference between what was billed and our maximum allowable fee, you will be responsible for that amount.
Maximum allowable fees apply to all services received from non-plan providers. This includes emergency or urgent care services and services for which you may have received an approved referral or prior approval. If you have an approved referral or prior approval to see a non-plan provider, you can find out if there is an amount you might owe before you even receive those services. Call our Customer Care Center with the name of the non-plan provider, the procedure code of the service you will be receiving, and the amount the provider will be charging.
Customer Care Center will then be able to tell you what amount, if any, you may owe.
When we pay up to our maximum allowable fees, please keep in mind that any policy copayments, deductible or coinsurance amounts will still apply to those services.
Mental Health and Alcohol and Other Drug Abuse Services
If you or your Primary Care Practitioner (PCP) determines that you need to seek mental health or alcohol and other drug abuse (AODA) treatment, you will need to know the following before you receive treatment:
When seeking outpatient treatment for a mental health condition, HMO members can make an appointment without a referral to any of the Dean Health Plan mental health providers. Please refer to your Dean Health Plan Provider Directory for a listing.
Point of Enrollment, Point of Service, and Triple Option members can make an appointment without a referral to any of the Dean Health Plan mental health providers. Services with a non plan provider require prior authorization. If the member is seeking mental health services with a non plan provider they will need to call into the Customer Care Center with the information including the name of the provider, address and phone number and date of appointment.
Alcohol and Other Drug Abuse
When seeking outpatient AODA treatment, HMO members need to make an appointment with a plan AODA provider. Please refer to your Dean Health Plan Provider Directory for a listing. Services with a plan AODA provider do not require an authorization.
If the member agrees, the AODA provider will coordinate treatment with the primary care practitioner.
Point of Enrollment, Point of Service, and Triple Option members can receive an outpatient AODA assessment from any plan or non plan AODA provider. If the AODA provider is not a plan provider they must contact Dean Health Plan for authorization for services.
If you are admitted to a hospital for any inpatient mental health or AODA detoxification treatment, the hospital admission must be certified with our Managed Care Division. We must be notified of any emergency mental health or AODA admission by the next business day. If the services are for inpatient AODA rehab the services must be preauthorized by the Behavioral Health case managers.
If you are a full-time student covered under your parent's HMO policy and you are attending school in Wisconsin but out of our service area, you may have some additional mental health and AODA benefits. You can receive an assessment by a non-plan provider that we designate. If outpatient treatment is recommended, five outpatient visits will be approved. Any further visits must be prior authorized with our Managed Care Division. Please keep in mind that you must still maintain your full-time student status while receiving this treatment out of the service area. If you are unable to maintain full-time status, you will need to return to our service area for any continued treatment.
Please refer to your benefit document for more information on coverage details including out of pocket costs and any limitations or exclusions.
If you have any questions about your mental health or AODA coverage, please be sure to contact our Customer Care Center.
Prescription Drug Benefit
Many of our policies cover "legend" prescription drugs. These are drugs which by law require a written prescription from your doctor. You can find your drug coverage outlined in your Schedule of Benefits. Here is the information you need to understand about your prescription drug coverage.
Generally, Dean Health Plan's policy for dispensing drugs is limited to a 30-day supply. If your plan is different it will be indicated in your Schedule of Benefits. Your Schedule of Benefits will also note if you have an annual prescription benefit maximum. Please check your Schedule of Benefits to verify what your specific policy allows.
Filling your Prescription
Your prescription may be filled at any of our plan pharmacies. Dean Health Plan requires that the generic equivalent be dispensed. A generic medication contains the same ingredients and is absorbed by your body to the same extent as brand name medication.
If you are out of the service area and need to fill a prescription, you can simply go to one of the national plan pharmacies that are listed in the Provider Directory or on our website at www.deancare.com. In most cases, these pharmacies will collect the appropriate copay and bill Dean Health Plan just as a local pharmacy would. This makes it easy for you, whether at home or away.
If a national plan pharmacy is not available, your prescription will be covered only if your policy has a non-plan provider benefit or if the prescription is for an urgent or emergency care situation. If you fill your prescription at a non-plan pharmacy, you will need to pay for the prescription and submit a claim to us for reimbursement in full minus any copayment.
Prior Authorization of Prescriptions
By requiring prior authorization for certain medications, we can help control escalating health care costs that affect your premiums. You may receive a list of the drugs that require prior authorization by calling our Customer Care Center. As outlined in the Member Certificate, if your physician prescribes one of these drugs, either your physician, the pharmacy or you can initiate a prior authorization request.
Occasionally, a prior authorization request may be denied. Should this occur, the requesting physician is always offered alternative drugs to prescribe that are covered by Dean Health Plan.
What is a drug formulary?
A drug formulary is a list of approved drugs that are covered with a copayment by the insurance company. Dean Health Plan's drug formulary contains over 1,800 drugs. You can find out what drugs are on our formulary online at www.deancare.com. There you will be able to search for drugs by name, category or subcategory. You can also refill your prescription online through a Dean Pharmacy.
Why do we use a drug formulary?
A drug formulary is a tool used by many insurance companies in an effort to standardize care, to improve the quality of care, and to reduce premium costs.
How are drugs added and excluded from the drug formulary?
Dean Health Plan's Pharmacy and Therapeutics committee meets regularly to review the effectiveness, safety, and costs of medications when making decisions about what to add and delete from the drug formulary.
Can an exception be made?
Providers or Members may request an exception to the benefit for reasons of medical necessity. If a formulary alternative is not appropriate or not effective, we will be happy to consider a formulary exception request. Prescribing physicians should have a drug prior authorization form that can be mailed or faxed. The Member Exception Form is available at deancare.com. If your physician or pharmacist has any questions about the exception process, please ask them to call Customer Care Center. The request is reviewed by the medical director and if approved, the medication is covered at the same level as a formulary drug.
Where do I get help if I have any questions?
Any questions regarding the drug formulary or the exception process should be directed to Customer Care Center by calling (608) 828-1301 or (800) 279-1301.
Insulin and Disposable Diabetic Supplies
Regardless of whether your policy has prescription drug coverage or not, you will always have coverage for insulin and disposable diabetic supplies as a Dean Health Plan member.
This coverage is for the treatment of diabetes and includes not only insulin but disposable diabetic supplies such as lancets, syringes, cotton and alcohol swabs, finger stick devices, blood or urine glucose strips, and control solutions for blood glucose monitors.
Your Member Certificate and Schedule of Benefits specifically outline what copayments will apply to this coverage and any dispensing limitations.
Obtaining Durable Medical Equipment and Supplies
Part of your benefit as a Dean Health Plan member also includes coverage for Durable Medical Equipment (DME). Some examples of DME include a wheelchair, crutches, splints, orthopedic braces, and other medically necessary supplies or medical equipment.
It is important to keep in mind that these items must be received from a plan DME provider, unless your policy specifically authorizes non-plan provider services. Please check your Provider Directory for a listing of plan DME providers. You will also need to follow any prior authorization requirements that are outlined in your Member Certificate or Schedule of Benefits.
We evaluate the cost of renting the equipment compared to purchasing it. This is based on how long you are expected to use the item. Also, we will only cover the standard models. Equipment with features beyond what is medically necessary are not covered.
If you have any questions about the type of DME covered under your policy, please contact our Customer Care Center.
Coordination of Benefits
What is COB?
It is very common for both spouses to be employed and as a result, to be insured by more than one health insurance plan. Similarly, one may be covered by both Medicare and a health insurance plan. Children can also be covered by more than one policy through their parents. Therefore, to address multiple health plan coverage situations, your Dean Health Plan policy contains a Coordination of Benefits (COB) provision.
Which Coverage is Primary?
When you are covered by more than one health insurance plan, one of them is considered primary and the other secondary. The primary plan pays its benefits first as if no other insurance coverage is involved. After the primary plan pays, the secondary plan determines its payment.
Wisconsin, along with many other states, has adopted rules which must be followed by all insurers who coordinate benefits. These rules are included in your Member Certificate, and can be complex. Please call the Customer Care Center if you are not sure which insurance is primary.
If you have Dean Health Plan and another health insurance plan, here are some common examples of how primary and secondary coverage is determined: (This is not all inclusive. If you have further questions, please contact Customer Care Center.)
When each spouse has family health insurance coverage, they each will have primary coverage for themselves and secondary coverage for their spouse under their respective plans. The spouse whose birth date occurs earliest in the calendar year provides primary coverage for their dependent children. The other spouse's coverage would be secondary.
In divorce situations, the birthday rule usually applies unless a court order specifies otherwise. Dean Health Plan requires a copy of the court order indicating who is to provide coverage for dependent children in divorce, custody, and paternity determination cases.
When you are covered by Medicare and another health insurance plan, many times Medicare is primary. One exception to this may be when your spouse or yourself are still actively employed and covered by a health insurance plan. In some cases that plan may be primary for the working and non-working spouse. Medicare would then be your secondary insurance. Each situation is different and Dean Health Plan will determine this based on federal guidelines.
Both Dean Health Plan and your health care provider need to be informed of all health insurance coverage.
Submitting a COB Claim
Claims for you and your family members must be sent to your primary plan first even if you believe the primary plan will not pay the claim. After your primary plan processes the claim, you will receive an Explanation of Benefits (EOB). The EOB will indicate what the primary plan did or did not pay.
If Dean Health Plan is your secondary health care plan, you must send your health care provider a copy of the EOB from your primary plan before we can determine benefits. Both your provider and Dean Health Plan need to be informed of all health insurance coverage or changes.
What Determines Payment?
If any portion of your health care visit is not paid by your primary insurance carrier, you will receive an Explanation of Benefits (EOB) or an Explanation of Medicare Benefits (EOMB).
It is important for you to submit the EOB or EOMB to your health care provider as soon as you receive it so that your claims can be processed promptly. Because there are two insurance companies involved, it may extend the processing time of your claim. The specific payment may vary depending on the coverage in your health insurance plan.
In order for services to be covered according to your policy, you must follow DHP requirements for coverage, such as seeing plan providers and obtaining referrals when necessary. One exception is if your primary insurance company, such as an HMO or PPO, is a plan that requires that you see its plan providers. In this case, DHP will process the services, subject to the policy provisions, if the requirements for plan providers and referrals were met on the primary plan.
We will periodically request updates from you regarding other health insurance coverage. If you receive a questionnaire, please complete it and return it to us. Doing so will help us process your claims promptly and correctly. Please inform us in writing if there are ever changes in other insurance coverage on any family members in the future.
Privacy and Confidentiality
Dean Health Plan, Inc. (DHP) protects the privacy of personal health information of each member from unauthorized and inappropriate use or disclosure.
- Subscribers sign a routine consent at the time of enrollment for release of member personal information and records for themselves and their enrolled dependents. This allows DHP to use member personal information and records, without specific consent, for the purposes described in this policy.
- DHP limits the internal use of personal health information wherever possible and ensures that only authorized staff with the need to know have access to it.
- DHP may collect and use personal health information for routine needs that include treatment, coordination of care, quality assessment and measurement (including surveys of members), health plan accreditation, billing and claims payment, reporting to state and/or federal agencies as required by law, health care research, and other communications with practitioners and providers related to providing services and treatment to members. In the use of personal health information, DHP may transmit personal information to people or organizations outside of DHP for these purposes.
- DHP affords the member an opportunity, in accordance with both state and federal laws, the right to consent to or deny the release of identifiable medical or other information, except when such release is required by law.
- When DHP transmits or releases personal health information to another organization, DHP requires that other organization to protect personal health information from unauthorized and inappropriate use or disclosure.
- Aggregated personal health information and data, in which personal health information is not identifiable, is not subject to privacy restrictions and may be used and disclosed by DHP without restrictions.
- DHP members have the right to access and review their personal medical records according to clinic policies and guidelines.
Quality Improvement Program
The Dean Health Plan (DHP) Quality Improvement (QI) Program provides standards to measure and assess quality of clinical care and quality of service delivered to members.
The QI Program was developed to help achieve the following goals:
- Assure that health care and the Customer Care Center are accessible and responsive to members' needs.
- Assure the provision of appropriate quality medical care to DHP members and their families.
- Assure the access and availability of such care through a network of primary and specialty care practitioners, inpatient and outpatient facilities, and ancillary service practitioners.
- Identify deficiencies in the care/service process and develop targeted interventions for improvement.
- Assure that behavioral health and medical care are integrated.
- Support improvement of members' health status through use of prevention, clinical practice guidelines, disease management programs, pharmacy initiatives, coordination of care and monitoring of underutilization and over-utilization.
- Identify potential patient safety issues, integrate corrective processes into existing programs/initiatives and monitor for improvement.
The QI Program's functions include:
- Annual Healthcare Effectiveness Data and Information Set* (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) data collection and analysis. Results are submitted to the National Committee for Quality Assurance* (NCQA).
- Coordinate the collection, analysis and reporting of data used in monitoring and evaluating care, including quality, utilization, credentialing and member service functions delegated to associated organizations.
- Identify opportunities to improve care and develop quality improvement interventions.
- Identify and address substandard care.
- Identify and address issues regarding patient safety.
- Identify opportunities to improve the service delivered to our members and develop improvement interventions.
- Track the implementation and outcomes of quality improvement interventions.
- Evaluate the effectiveness of improving care and services.
- Conduct credentialing and re-credentialing activities for all participating practitioners and providers.
- Conduct ongoing monitoring of care and services provided by physicians and other providers between re-credentialing cycles.
*HEDIS is a set of standardized performance measures. CAHPS is a standardized survey that asks consumers and patients to report on and evaluate their experiences with health care. DHP reports their HEDIS and CAHPS scores on an annual basis to NCQA, which uses this information when accrediting health plans.
At some time during your life, you may be involved in an accident. For example, you could fall on an icy sidewalk or be involved in an automobile collision. Occasionally there is another party involved in the accident who should be responsible for the resulting expenses.
If you were injured in the accident and needed medical care, your expenses would be paid by your Dean Health Plan policy. In turn, Dean Health Plan would try to recover the money spent on your injuries. This attempt to recover money from the liable party is known as subrogation.
If you or a family member are injured in an accident, it is important that you notify Dean Health Plan. If you are dealing with an insurance company and/or an attorney, please let us know their names, addresses, and telephone numbers.
Dean Health Plan has an obligation to all of its members to pursue subrogation because we want to do our part to keep the costs of your health care down.
In order for services to be covered according to your policy, you must follow DHP requirements for coverage, such as seeing plan providers and obtaining referrals when necessary. For a more complete description of Dean Health Plan's subrogation rights, please refer to your Member Certificate.
A member may be identified for case management based upon a diagnosis, acute injury or from a referral by a healthcare provider. You also have the option to request Case Management services. Case Management is free of charge and provides you with a registered nurse who serves as your resource during a time where health care may be intense or confusing. Your Case Manager will work together with you, the health care provider and other members of the health care team as needed to establish the best plan of care for you. Case Management does not provide additional benefits or change your plan's benefit rules; however, the case manager will work with DHP network providers to meet your needs using available resources with the goal of delivering quality cost-effective care.
The DHP Utilization Management (UM)* team uses pre-admission certification, prior authorization, concurrent reviews and discharge planning to review the appropriateness of medical services that our members receive before and after services are rendered. These tools allow UM to ensure members are receiving services and supplies that are medically appropriate for the member and necessary for the condition being treated. The review of services includes inpatient hospital admissions, skilled nursing facility and rehabilitation care, home health care services, hospice care and behavioral health outpatient care. In addition, UM identifies and evaluates a patient's health care needs following discharge from a hospital and assist members with post hospital care.
Every year Dean Health Plan (DHP) evaluates new medical technology and reviews existing technology to determine if any changes or updates are needed to guidelines outlining appropriate use to ensure you receive the most current and effective treatment. During this process, DHP reviews requests for ongoing care or treatment recommendations for all Utilization Management (UM) decisions, including medical, behavioral health care, pharmaceuticals and medical devices. Nationally recognized resources are used to determine if the technology offers improved outcomes when compared with established products, procedures and behavioral health technologies. Drugs covered under the DHP pharmacy benefit are also reviewed by a DHP medical director along with pharmacists from Dean Health System and Navitus Health Solutions. Whether a product or process is reviewed before or after implementation, DHP follows the review process set by the National Commission for Quality Assurance (NCQA). Based upon the results of the technology assessment, DHP will draft or revise their medical policies if necessary.
Dean Health Plan Grievance and Appeals Process
We know that at times you may have questions and concerns about benefits, claims or services you have received 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.
If after contacting us, you continue to feel a decision has adversely affected your coverage, benefits or relationship with Dean Health Plan, you may file a grievance (sometimes called an appeal). Upon receipt of the grievance, the Grievance and Appeals Department will acknowledge your grievance within five business days. Our acknowledgment letter will advise you of your right to submit written comments, documents or other information regarding your grievance; to be assisted or represented by another person of your choice; to appear before the Grievance Committee; and the date and time of the next scheduled meeting, which will not be less than seven calendar days from the date of your acknowledgment and within 30 calendar days of receiving the grievance. If you choose to appear before the Committee, you must notify us. If you are unable to appear before the Committee, you do have the option of scheduling a conference call. Your grievance will be documented and investigated. All grievances will be resolved within 30 calendar days of receipt. You have the right to request a copy of documents, free of charge, relevant to the outcome of your grievance by sending a written request to the address listed below.
If your grievance is determined to be urgent in nature, you may be entitled to an expedited grievance which will be resolved within 72 hours of the receipt. If your grievance meets criteria for an expedited grievance, meaning your situation is deemed urgent in nature or you are receiving ongoing treatment, you are also eligible for an expedited external review concurrent with the internal expedited review of your grievance.
After the internal grievance process is completed, you may also be entitled to an independent external review (IER) if the outcome of your grievance involves care that has been determined not to meet the policy requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of care or where the requested services are considered experimental or investigational. Pre-existing Condition determinations and Policy Rescissions are also eligible for IER. You must exhaust all appeal/grievance options before requesting an independent external review. However, if we agree with you that the matter should proceed directly to independent review, or if you need immediate medical treatment and believe that the time period for resolving an internal grievance will cause a delay that could jeopardize your life or health, you may ask to bypass our internal grievance process. In these situations, your request will be processed on an expedited basis. If you or your authorized representative wish to file a request for an independent review, your request must be submitted in writing to the address listed below and received within four months of the decision date of your grievance. Upon receipt of your request, a URAC accredited IER will be assigned to your case through an unbiased random selection process. The assigned IER will send you a notice of acceptance within one business day of receipt, advising you of the right to submit additional information. The assigned IER will also deliver a notice of the final external review decision in writing to you and Dean Health Plan within 45 calendar days of their receipt of the request. A decision made by an IER is binding for both Dean Health Plan and the member with the exception of pre-existing condition exclusions and the rescission of a policy or certificate. You are not responsible for the costs associated to the IER.
The Grievance and IER procedures are also described in your plan-specific Member Certificate/Handbook available from our Member Document Center. Please refer to this document to determine eligibility for IER rights. You may also contact our Customer Care Center at (800) 279-1301 with any additional questions regarding these processes.
You may initiate the Grievance process by submitting your complaint to us in writing to:
Dean Health Plan, Inc.
Attention: Grievance and Appeals Department
P.O. Box 56099
Madison, WI 53705
Services Obtained Outside the System or Service Area
Benefit restrictions that apply to services obtained outside the system or service area vary based on plan design. Please go online to view your member certificate for specifics based on your plan. Please call the Customer Care Center if you have questions.
How to Obtain Specialty Care
Specialty care is subject to co-insurance and/or deductibles. Please refer to your Health Insurance Benefit Summary for complete details.
Hospital Services are subject to co-insurance and/or deductibles. Please refer to your Health Insurance Benefit Summary for complete details.