Appeals And Grievances

Member Administrative Review and Grievance Procedures

 

Administrative Reviews and Grievances

You can make a complaint if you have problems with the care you get. “Administrative Reviews” and “Grievances” are the 2 types of complaints you can make. 

 

An Administrative Review is when you want us to change a decision we made about your care.  It could be:

 

• If we refuse to pay for services you think we should cover
• If a doctor didn’t give you care you think you should have received
• When a doctor cuts back services you had been getting
• If you think we stopped your care too soon

 

A representative can file one of these for a member who died. 

 

A Grievance is when you have any other type of problem with the plan or a doctor.  It could be for:

 

• Quality of care
• Wait times during doctor visits
• The way your doctor or others behave
• Not being able to reach someone by phone
• Not getting information you need
• Not getting information you need

 

Making a Complaint to Change a Decision on What the Plan Will Pay For

 

Here we tell you what you can do if you have problems getting the care you think we should give you.  Giving care includes things like:

 

• Approving care
• Paying for care
• Assigning someone to your care
• Continuing to provide care you have been getting

 

Problems getting the care you think we should give include:

 

• If you are not getting the care you want, and you think the plan should pay for it
• If we will not approve the care your doctor or other doctors want to give you, and you think the plan should pay for this care
• If you learn that we plan to reduce or stop paying for care you have been getting, and you think this will harm your health
• If you get care you thought the plan would pay for, and we said we would not pay

 

Asking for Care or Payment from the Plan

 

You can take two steps if you have problems getting care or paying for care.  A new person will take a look at your case. He/she will not have been part of the first decision. This person will also be someone who did not work directly with anyone in the first decision. If you aren’t happy with the result, there may be another step you can take.

 

Step 1—Notice of Proposed Action by the Plan

First, we will send you a Notice of Proposed Action. It talks about your care or paying for care you already received. When we make an action, we give our view of how care for members applies to your specific case. You can ask for a “fast initial decision” if you have a request for quick care. In the review, you or your representative can look at your case papers and care records.
 

 

Step 2—Administrative Review of the Notice of Proposed Action by the Plan

If you don’t like what we decide in the first step, you, your doctor or representative can ask us to reconsider. This is known as an “administrative review” or a “request for reconsideration.” You can ask for a quick review. We will decide to change or keep the first decision.

 

Q. How do I file my administrative review of the Notice of Proposed Action?

A. You, your doctor or representative can file for a review. You can write us to ask for a review. You must also fill out a review request form. You can get this form from Customer Service. Call 1-866-231-1821 (TTY/TDD: 1-877-247-6272).
 

You can also give it verbally. You must sign a review request form if you give it verbally. This is only if it is not a fast or quick review.

We will mail you a letter within 10 days saying that we received your review. This is only if it is not a quick review. We will send you a decision letter instead if we decide on your review in less than 10 days.

 

Q. How soon must I file my administrative review?

A. Send it within 30 days of the date when we notified you. We will mail you a denial if we don’t get the request in time.
 

 

Q. How do I get benefits when I’m waiting on a review decision? What rights do I have?

A. Please see “How can my benefits be continued during a review or hearing” later in this section.

 

Q. What if I want a fast review?

A. You, any doctor or representative can ask us for a fast review. Call Customer Service. Mail a written report to:

 

We will also send you a letter within 2 days. You will need to ask your doctor to support a fast review. If your doctor agrees, we will give you a review right away. The letter will tell you how to send a complaint if your doctor doesn’t support a fast review and you don’t like what your doctor says.

A regular review is in 45 days.

 

Q. How soon must the plan decide on my review?

A.  For payment for care you received—a regular review is within 45 days after we get your review.  For a standard decision about care—a regular review is within 45 days after we get your review. We will make it sooner if your health requires it.  For a fast decision about care—we have 72 hours after we get your review to decide. We will make it sooner if your health requires us to.  It can take up to 14 more days if you ask for a longer review. This is called an extension. It will give 14 more days for the review. You can ask for this in writing or by phone. Reasons why you may need a longer review include:

 

• Extra tests
• Delay of records
• Need time to get more information

 

We will mail you a letter called a “Notice of Adverse Action.” It will talk about your rights to disagree if a decision is not in your favor. We will also try to contact you in person.

 

Q. How can I give proof and/or allegations of fact or law?

A. We will let you give comments or information for your review in writing or in person. Call 1-866-231-1821 (TTY/TDD: 1-877-247-6272) to give this in person.

 

Q. Can I review my case file?

A. Yes. Your doctor or representative can review it as well, if you let us know in writing. Call Customer Service at 1-866-231-1821 (TTY/TDD: 1-877-247-6272) if you need help with this.

 

Appealing for an Administrative Law Hearing or DCH Hearing

You can ask for a hearing with an Administrative Law judge (Medicaid) or a DCH hearing (PeachCare for Kids™) if you don’t like the review decision.  You must ask for a hearing within 30 days of the decision.  Write to:

 

Medicaid–Department of Community Health
Legal Services Section - General Counsel’s Office
Two Peachtree Street, NW 40th Floor
Atlanta, GA 30303-3159

 

 

You or your representative are the only ones who can request a hearing. Your doctor cannot. You must request a hearing within 30 days of the review decision. A hearing is a meeting with you, someone from WellCare and a hearing officer. WellCare will explain why we made our decision. You will tell why you think we made the wrong decision. The hearing officer will listen. He or she will then decide if we followed the rules and who is right based on the information given.

 

Q. How can my benefits be continued during a review or hearing?

A. For your benefits to continue:

• The review or hearing must be about an end or reduction in care
• The care must have been asked for by a plan doctor
• The original pay term for care cannot be expired
• You must request a longer term for care

We will mail you a denial letter if you do not ask for this in time.

 

If we let your benefits continue during a review or hearing, you can keep getting them until:

 

• You drop the review or hearing
• 10 days pass from a verbal request (15 days from a mailed request). This is from the date of the plan’s action. You must not have requested a hearing with benefits until we have decided
• A decision you don’t like is made
• The care approval expires or service limits are met

 

You may have to pay for the cost of your care during a review or hearing. This is if we don’t agree with your complaint.

 

If we don’t decide in your favor, the plan may recover the cost of care during your case. If we decide in your favor and you didn’t get benefits during your case, we will get you care right away. We will approve and pay for the care.

 

By state law, we will pay for services you did not agree with during your review or hearing.

 

To file an Administrative Review

 

Making Complaints to the Plan for Issues Not Classified as Administrative Reviews

First, call Customer Service with a complaint. A doctor may not make a complaint for you. We must get a complaint within 1 year of when the issue you were unhappy about took place. We will try to fix the problem over the phone. You can also write to us with your complaint.

 

You have the right to complain about:

• You drop the review or hearing.
• Office waiting times
• Doctor behavior
• Condition of the places where you get care
• If you were taken out of the plan without asking
• If we don’t give you a fast review
• If we don’t give you a longer review time

 

We will try to fix any complaint you have. We try to do this by phone, especially if it is because:

• We don’t have enough information.
• We don’t have the right information.

We make decisions within 90 days of getting your complaint. We will mail you a letter with the results. It will tell you how to make a second-level complaint.  You must write to us with a second-level complaint. You should send this within 30 days of getting your decision. Send the letter to the Appeals and Grievance Committee (AGC). The AGC is made up of members who were not first involved with your case.

You can also make a second-level complaint in person. Tell us about this in your written request. The AGC meets every Thursday from 9:00 am to 10:30 am Eastern. We will touch base with you to set up a time.  You will have 15 minutes to give your side of the case. The AGC will then ask any questions. You will get a decision letter within 5 days of this meeting.

Some other contacts for a review or complaint:

Exhaustion of Grievance Procedures

 

You must take part in the plan’s review and complaint process before you can take legal action.

 

To file a Grievance

 

We keep track of all reviews and complaints to help us improve our service to you.   We give this information to the State.

Last modified: 07/25/2011