DeanCare Gold (Cost) grievance & appeal rights

Information about coverage decisions, complaints and premium assistance

About DeanCare Gold

Limitations, copayments and restrictions may apply. Benefits, network premium and/or copayments/coinsurance may change on Jan. 1st of every year. You must continue to pay your Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.

For more information, contact Dean Health Plan. Dean Health Plan contracts with the federal government.

Senior couple with their grandson

CONTRACTING

By law, DeanCare Gold can choose not to renew its Medicare contract. Medicare may also refuse to renew the DeanCare Gold contract, resulting in a termination or non-renewal. This may result in termination of the beneficiary's enrollment in DeanCare Gold. In addition, DeanCare Gold may reduce its service area and no longer offer services in the area where the beneficiary resides.

PLAN RATINGS

The Medicare program rates how well plans perform in different categories, such as customer service, detecting and preventing illness and ratings from patients, among others. You can use the web tools at The Official U.S. Government Site for Medicare to compare the plan ratings for Medicare plans in your area or see how Dean Health Plan rates. To obtain a copy of the plan ratings you may also call Medicare directly at (800) MEDICARE (633-4227), or TTY call 1-877-486-2048 (24 hours a day/seven days a week).

COMPLAINTS, GRIEVANCES AND APPEALS

Federal law guarantees your right to make complaints if you have concerns or problems with any part of your medical care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when someone makes a complaint.

grievance is any complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with us or one of our network providers not relating to coverage from the plan.

An appeal is any of the procedures that deal with the review of an unfavorable coverage determination. You cannot request an appeal if we have not issued a coverage determination. If we issue an unfavorable coverage determination, you may file an appeal called a "redetermination" if you want us to reconsider and change our decision. If our redetermination decision is unfavorable, you have additional appeal rights. More information on this process can be found in chapter 7 of your plan's Evidence of Coverage.

If you would like to request an organization determination or make an appeal, you may make your request in writing or verbally. The mailing address to send your written requests is:

Dean Health Plan
PO Box 56099
Madison, WI 53705

You can also submit your organization determination or appeal request by telephone by calling the Customer Care Center at 1-888-422-3326 (TTY: 711). (Calls to these numbers are free.) You may also fax your request to: 1-608-252-0812.

See more on our grievances and appeals process.

If you have questions on this process or wish to check the status of your request for an organization determination or appeal you can call our Customer Care Center at the numbers above.

If you wish, you can name another person your “representative”, which allows them to request an organization determination or make an appeal on your behalf. If you want a friend, relative, provider, or other person to be your representative, call the Customer Care Center at the number above and ask for the Appointment of Representative form. When you complete that form, that person will have permission to act on your behalf. The form must be signed by you and by the person who you would like to act on your behalf. You must give our plan a copy of the signed form. There may be someone who is already legally authorized to act as your representative under State law. If that is the case, a copy of such legal authorization needs to be provided to our plan. You can also download a copy of the Appointment of Representative form required to grant this permission to an individual of your choosing.

COVERAGE DETERMINATION, APPEALS, COMPLAINTS, PREMIUM ASSISTANCE

Learn more about your plan's coverage determination, appeals and complaints process
See chapter 9 of your plan’s Evidence of Coverage (EOC). For data on the number of grievances and appeals for Dean Advantage, contact our Customer Care Center at 1-877-232-7566 (TTYT: 711).

Coverage determination
Coverage determinations are the first decision made by the plan on the medical care you are requesting or the drugs(s) or payment you need.

standard coverage determination for medical care means we will give you an answer within 14 calendar days after we receive your request. A fast coverage determination means we will answer within 72 hours.

standard coverage determination for drugs means we must give you our answer within 72 hours after we receive your request. For a fast coverage determination about the drug(s) or payment you need, we must give you our answer within 24 hours.

See the latest National Coverage Determination updates

Requesting a coverage determination
To request a coverage determination for medical care, drugs or payment, you, your appointed representative or physician should contact us by telephone, fax or mail at the contact info below:

PHONE

1-608-828-1978 or 1-888-422-3326
Medical fax for Medical coverage determination: 
1-608-252-0840

MAIL

Dean Health Plan Medicare Advantage
1277 Deming Way
Madison, WI 53717

You, your prescriber or member representative may ask for a coverage determination via secure email outlined in the CMS drug coverage determination form.


APPEALS & GRIEVANCES (PART C)

An appeal means we will review an unfavorable coverage determination. You can file an appeal if you want us to reconsider a decision we have made about your Part C medical prior authorization or Part C medical claim or cost share associated with your Part C medical coverage.

  • standard appeal decision means we have up to 30 calendar days for pre-service (prior authorization) appeals, and 60 calendar days for post-service (claim) appeals from the time we receive your request to make a decision on a standard appeal.
  • fast appeal decision means we have up to 72 hours from the time we receive your request to make a decision on a fast appeal. 

grievance is any complaint or dispute (dissatisfaction) other than one involving an organization determination. It is different from a coverage determination request; it usually will not involve coverage or payment for Part C medical benefits.
 
We make grievance decisions as quickly as your case requires but no later than 30 calendar days after receiving your complaint.
 
If you request a fast grievance, and your request meets our fast grievance criteria, we will render a decision within 24 hours.

Requesting a Part C appeal or grievance
In most cases you only have 60 calendar days from an event to file a grievance or appeal. You may be eligible to file a grievance or appeal after 60 calendar days when you provide a good cause reason for missing the deadline. If we do not accept your good cause reason, we will notify you in writing.

To check status or to request a standard, fast or expedited appeal or a grievance, you, your appointed representative or your prescribing physician should contact us by telephone, fax, mail or hand-deliver at the numbers or address below:

PhoneMailIn person
1-866-270-3877Dean Health Plan
Attn: Part C Member Appeals Department
P.O. Box 56099
Madison, WI 53705
Fax: 1-608-252-0888
Dean Health Plan
1277 Deming Way
Madison, WI 53717

 

QUALITY IMPROVEMENT ORGANIZATION (QIO) APPEAL (PART C)

You may request a review by Livanta, a Quality Improvement Organization (QIO), if your complaint relates to one of the following situations:

  • You have a complaint about the quality of care you have received.
  • You think coverage for your hospital stay is ending too soon.
  • You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

Livanta can be reached at 1-888-524-9900 or by postal mail at the following address:
Livanta BFCC-QIO
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701

You must act quickly when filing with Livanta as a request must be made before you leave the hospital and no later than your planned discharge date.

YOU HAVE CHOICES IN YOUR HEALTH CARE

DeanCare Gold is a Medicare approved HMO. You must use plan providers, except for emergency and urgent care, or when you receive a referral to a non-plan provider. You may receive services from non-plan providers for other than these situations, but you will be responsible for payment of all Medicare deductibles and co-insurance, as well as any other charges prescribed by the Medicare program. DeanCare Gold materials are available in alternative formats.

MEDICARE COST INSURANCE

The Wisconsin Insurance Commissioner has set minimum standards for Medicare Cost insurance. These plans meet these standards. For an example of these standards and other important information, see the "Wisconsin Guide to Health Insurance for People with Medicare."

Dean Health Plan, Inc. is contracted with Medicare to provide Medicare benefits.

DeanCare Gold offers three plans, an Enhanced plan, a Shared Value plan, and a Basic plan. The Basic plan provides only basic Medicare-covered hospital and physician benefits. The Enhanced and Shared Value plans also provide basic Medicare-covered benefits, but include benefits beyond those provided by Medicare (such as, but not limited to, routine hearing and vision tests, routine physical exams and hearing aids). Please contact our Customer Care Center at 1-888-422-3326 (TTY: 711), for additional information about these plans.

RIGHT TO DISENROLL FROM PLAN

You may disenroll from DeanCare Gold at any time for any reason. However, it may take a few weeks to process your disenrollment, update your Medicare record and return you to the Original Medicare program. Your disenrollment will become effective on the day you return to Original Medicare or enroll in another Medicare plan. You will receive written confirmation from Dean Health Plan, Inc. of your disenrollment effective date, and Dean health Plan, Inc. will return any paid, unused premium to you.

READ YOUR EVIDENCE OF COVERAGE CAREFULLY

The plan comparisons on this website are only summaries describing DeanCare Gold's most important features. The Evidence of Coverage is the insurance contract. You must read the Evidence of Coverage itself to understand all of the rights and duties of both you and Dean Health Plan, Inc.

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We're here to help

Have questions about your DeanCare Gold Medicare insurance coverage? Contact the Customer Care Center at  1-888-422-3326 (TTY: 711).

For DeanCare Gold information in alternate formats and languages, call our Customer Care Center.
Mailing Address:
Dean Health Plan
PO Box 56099
Madison, WI 53705

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