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 and appeals procedure
A grievance is any dissatisfaction with us, including the way we provide services or process claims, or a decision to change or rescind a policy. A grievance must be expressed in writing to us by, or on behalf of, a Member.
This grievance 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 formulary exception process described later in this section.
To file a grievance, you or your authorized representative must send your grievance 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, 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;
- 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.
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 will be documented and investigated. So that you will have time to respond prior to our grievance decision, we will automatically send you the following information:
- Any new or additional evidence we consider, rely upon, or generate in the course of considering your grievance; or
- Any new or additional rationale we use to make our decision.
If you wish to receive a free copy of any other documents relevant to the outcome of your grievance, send a written request to the address listed above. All grievances will be resolved within 30 calendar days of the day we receive your request.
If we decide your grievance is urgent according to our criteria, we will resolve your grievance within 72 hours of the time we receive it. Our criteria are based on the expedited grievance provisions of applicable law.
We will automatically treat your grievance as expedited if:
- Your concerns are related to a facility admission or concurrent review of a continued facility stay;
- Our Medical Director decides your life, health, or ability to regain maximum function could be jeopardized by the standard review timeframe;
- 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
- 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 either orally by calling 608-828-1991, in writing at the address listed above, or via fax at 608-252-0812. You can make this request in your initial grievance or in a separate communication.
If you are eligible for an expedited internal grievance 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 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:
- Medical Necessity
- Health care setting
- Level of care
- 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.
You must exhaust our internal review process before you can request an external review unless:
- We fail to comply with internal claims and appeals requirements;
- You request an expedited external review when you request an expedited internal review; or
- 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.
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:
- By directly submitting the request online at externalappeal.com
- 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
- By mailing the request to Us at the address listed in section B of this chapter, which describes the grievance process; or
- By faxing the request to (888)-866-6190.
If you choose to mail or fax your request, you can either print the online form, or you can provide the following information in a letter:
- Phone number
- Email address
- Whether the request is urgent
- Member’s signature if the person filing the appeal is not the Member
- A brief description of the reason you disagree with your plan’s initial decision.
- Documents to support the claim, such as letter’s from your Health Care Provider, reports, bills, medical records, explanation of benefits (EOB) forms (optional)
- Letters sent to your health insurance plan about the denied claim (optional)
- Letters received from the health insurance plan (optional).
You can use the online form or call 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:
- You have asked for an expedited grievance and want an expedited external review concurrently (at the same time) and the timeframe for an expedited grievance (72 hours) would place your life, health, or ability to regain maximum function in danger; or
- You have completed the grievance process described above and the decision was not in your favor, and:
- The timeframe to do a standard external review (45 days) would place your life, health or ability to regain maximum function in danger; or
- 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 call 608-266-0103 (Madison) or toll free at 800-236-8517 (Statewide).
Formulary Exception Request
If your prescribing Health Care Provider feels it is Medically Necessary to prescribe to you a drug that is not on Our formulary, you can ask Us to make an exception.
You must request an exception within 60 calendar days of our initial coverage denial.
To ask for an exception you must fill out our formulary exception request form. You can either get the form by calling Our Customer Care Center at 800-279-1301 (TTY: 711) or you can get it on deancare.com. You or your prescribing Health Care Provider must send the completed form via mail or fax as indicated on the form.
Our timeline for considering your exception request will vary based on the urgency of your situation.
Standard Formulary Exception Request
If your request is not urgent we will follow our standard formulary exception request 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. If we approve the exception request, we will cover the drug until your prescription expires, including refills.
Expedited Formulary Exception Request
If you need the requested drug more urgently, we will follow our expedited formulary request timeline.
Urgent circumstances exist when:
- you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain function, or
- 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. If we approve your request, we will cover the drug for as long as your circumstances remain urgent.
If we deny your standard or expedited 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 60 calendar days of our denial.
For instructions on how to submit a standard external review of your exception request, see the Standard External Review section above. For instructions on how to submit an expedited external review of your exception request, see the Expedited External Review section above.