Caring Starts with Your Rights

Care Wisconsin protects member rights and has clear policies and procedures to address the concerns of members if they or their representatives are ever dissatisfied with decisions or services. We have a well-defined process that meets all Wisconsin Department of Health Services (DHS) requirements. We encourage members to exercise their rights and our goal is for the member to have a positive experience.

If you are unhappy or dissatisfied with a decision, first discuss it with your care team. Talking with your team is usually the fastest and easiest way to address your concerns.

If you do not want to talk with your team, call our Member Rights Specialist at 1-800-963-0035 ext. 3448 Monday-Friday. 8 a.m.-4:30 p.m. Our Member Rights Specialist can tell you about your rights, attempt to informally resolve your concerns, and help you file a grievance or appeal.

Understanding Grievances & Appeals

A grievance is when you are not satisfied with Care Wisconsin, one of our providers, or have concerns about the quality of your care or services. For example, you might want to file a grievance if your in-home personal care worker often arrives late, you feel your team doesn’t listen to you, or if you have trouble getting appointments with a certain provider. Unlike appeals, you can file a grievance at any time.
An appeal is a request for a review of decision made by Care Wisconsin. For example, you can file an appeal if your care team denies a service or support you requested. Other examples are decisions to reduce, end, or to deny payment for a service that is included in Care Wisconsin’s benefit package.

It’s often best to make your appeal as soon as you hear about the adverse decision. Please see the time limits for appeals below:

• Medicare appeals – 60 days to file
• Medicaid appeals to Care Wisconsin Grievance and Appeals Committee – 60 days to file
• Medicaid appeals to a State Fair Hearing – 45 days to file

Grievances & Appeals Process

The first step of any grievance is to contact your care team. Your team can work with you to quickly and informally resolve any concerns you may have. If you don’t feel comfortable or don’t want to discuss your concerns with your team, you may contact a Member Rights Specialist at Care Wisconsin. A Member Rights Specialist, like your care team, can work with you to informally address your concerns.

If this process does not address your concern to your satisfaction, you have three options:
1. File a grievance with Care Wisconsin. We will work with you to reach an agreement, or we can take your grievance to our Grievance and Appeals Committee.
2. File a grievance with the Wisconsin Department of Health Services (DHS). DHS will work with another agency to reach an agreement.
3. File a grievance with the state’s Division of Quality Assurance (DQA). Grievances for the DQA are best suited for situations when a caregiver or other provider has violated state or federal laws.
To make a complaint or grievance regarding a Medicare service, use the Medicare Complaint Form.
To make an appeal, first contact the Member Rights Specialist at Care Wisconsin. The Member Rights Specialist may be able to help you reach an agreement without filing a formal appeal. If you and the Member Rights Specialist are not able to reach an agreement, you have three options for making an appeal:
1. File an appeal with Care Wisconsin. We will work with you to reach an agreement, or we can take your appeal to our Grievance and Appeals Committee.
2. File an appeal with the Wisconsin Department of Health Services (DHS). DHS will work with another agency to reach an agreement. You may choose to file your appeal with the DHS first, or you may take your appeal to DHS if you disagree with Care Wisconsin’s decision on your formal appeal.
3. File an appeal with the state’s Division of Hearings and Appeals (DHA). An administrative law judge will make a decision about your appeal and issue a decision to you in writing. For most appeals, the DHA is the final stage.
Your Member Handbook or Evidence of Coverage has more information on grievances and additional levels of appeals.

Contact Information By Program

Care Wisconsin’s Member Advocate: 1-800-963-0035 x. 3448
Or write to:
Care Wisconsin Health Plan
ATTN: SSI Member Advocate
1617 Sherman Avenue
Madison, WI 53704

To speak with someone outside of Care Wisconsin, contact the HMO Enrollment Specialist:
1-800-291-2002

Or write to:
Medicaid SSI
Managed Care Ombuds
P.O. Box 6470
Madison, WI 53716-0470

You have the right to appeal to the State of Wisconsin Division of Hearings and Appeals (DHA) for a fair hearing if you believe your benefits have been wrongly denied, limited, reduced, delayed or stopped. An appeal must be made no later than 45 days after the date of the action being appealed. If you appeal this action to DHA before the effective date, the service may continue. You may need to pay for the cost of services if the hearing decision is not in your favor.

If you want a fair hearing with the DHS, send a written request to:
Department of Administration
Division of Hearings and Appeals
P. O. Box 7875
Madison, WI 53707-7875
Care Wisconsin’s Member Rights Specialist:
1-800-963-0035 ext. 3448

Or write to:
Care Wisconsin Health Plan
ATTN: Member Rights Specialist
1617 Sherman Avenue
Madison, WI 53704

To mail a written request for a Part D drug Coverage Determination:
Care Wisconsin Health Plan
ATTN: Pharmacy Services
1617 Sherman Avenue
Madison, WI 53704

To mail a written request for a coverage re-determination:
Care Wisconsin Health Plan
ATTN: Member Rights Specialist
1617 Sherman Avenue
Madison, WI 53704
Care Wisconsin’s Member Rights Specialist:
1-800-963-0035 ext. 3448

Or write to:
Care Wisconsin Health Plan
ATTN: Member Rights Specialist
1617 Sherman Avenue
Madison, WI 53704

To file a complaint directly with Medicare, follow this link.

To mail a written request for a Part D drug Coverage Determination:
Care Wisconsin Health Plan
ATTN: Pharmacy Services
1617 Sherman Avenue
Madison, WI 53704

To mail a written request for a coverage re-determination:
Care Wisconsin Health Plan
ATTN: Member Rights Specialist
1617 Sherman Avenue
Madison, WI 53704

Providers

Submitting a CORRECTED CLAIM for a PARTIALLY DENIED CLAIM where the information submitted was incorrect:
- Complete a new claim form with accurate information using the appropriate claim form and instructions. The new claim form must include ALL services billed on the original submission, not just those services that are being changed.
- Indicate “Corrected Claim” in bold letters at the top of the form and include the claim number from the original claim, if possible.
- Staple a cover sheet on the claim form stating “Attached is a corrected claim form for consideration”. Each corrected claim form requires its own cover sheet.
- Mail corrected form to:
  Care Wisconsin
  P.O. Box 226897
  Dallas, TX 75222-6897
Re-submitting COMPLETELY DENIED CLAIM where the information was incorrect:
- Prepare the claim with the correct information on a new claim form and submit the claim form in the normal way.
If your claim was partially or completely denied for a reason other than incorrect information:
- First, contact the Provider Help Desk for clarification about the denial. If you still believe that the denial or underpayment was in error, you may send a request for an appeal.
- You must submit your appeal in writing within 60 calendar days of the denial by sending a letter marked “Appeal” with specific information to:
  Care Wisconsin
  Attn: Claims Appeals
  1617 Sherman Ave.
  Madison, WI 53704

Resource Downloads For Grievances & Appeals

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