DeanCare Gold (Cost) grievance + appeal rights

Information about coverage decisions, complaints + premium assistance

About DeanCare Gold

Your benefits, network premium, and cost-sharing responsibilities

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. This benefit information is a brief summary, not a comprehensive description of benefits.

We contract with the federal government. For more information, contact us.

Contracting

By law, we can choose not to renew our Medicare contract. Medicare can also refuse to renew the contract. This may result in a termination of your enrollment in this plan. In addition, we may also reduce the service area and no longer offer services where you live.

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 we rate. To get 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, + 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.

A 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 in-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 and you want us to reconsider our decision, you may file an appeal called a "redetermination." 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 your appeal verbally or in writing, you can submit your organization determination or appeal request by calling Member Services toll-free at 1-888-422-3326 (TTY: 711). You can also fax your request to 1-608-252-0888.

See more on our grievances and appeals process.

Call Member Services with questions about this process or to check the status of your request.

You can name another person to be your representative. This will allow them to act on your behalf to request an organization determination or make an appeal.

Download and complete the Appointment of Representative (PDF) form. You can also call Member Services to request the form. 

When completing the form, keep in mind:

• Signatures from you and the person you'd like to appoint as your representative are required. 
• Once you've completed the form, that person will have permission to act on your behalf.
• You must give us a copy of the signed form.
• There may already be someone who is legally authorized to act as your representative under state law. If so, we need a copy of that legal authorization too. 

Coverage determination, appeals, complaints, + premium assistance

See chapter 9 of your plan’s Evidence of Coverage (EOC). For data on the number of grievances and appeals call Member Services at 1-888-422-3326 (TTY: 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.

A 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.

A 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:

Phone

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

Mail

Dean Health Plan by Medica
P.O. Box 56099
Madison, WI 53705

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.

• A standard appeal decision for pre-service (prior authorization) appeals means we have 30 calendar days from our receipt of your request to make our decision.
• A standard appeal decision for post-service (claim) appeals means we have 60 days from our receipt of your request to make our decision.
• A fast appeal decision means we have up to 72 hours from our receipt of your request to make our decision.

A 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:

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 mail at:
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 (PDF).

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 Member Services at 1-888-422-3326 (TTY: 711), for additional information about these plans.

Your right to disenroll from your 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'll get written confirmation of your disenrollment date from us and we'll return any paid but 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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