STATE OF IOWA
COMPLAINT, APPEAL AND EXTERNAL REVIEW RIGHTS
How to file a Complaint:
We encourage you to contact a customer service representative if you have an inquiry, concern, or complaint against us, or one of our participating providers. The customer service representative acts as an intermediary to resolve any of your issues. You may contact Customer Service at (608) 775-8007 or toll free at (800) 897-1923.
If you have questions or require language assistance, please call Customer Service. For people who are deaf, hard of hearing or speech impaired, please call TTY 711 or toll free 800-877-8973, or you may call through a video relay service company of your choice. Interpreter services are provided free of charge to you.
If the customer service representative is unable to resolve the issue to your satisfaction, they will advise you of your right to submit a written appeal to the member advocate. The member advocate is an individual employed by us specializing in the appeal process. The member advocate will receive and record your written appeal. The member advocate will have your appeal investigated by the appropriate staff and assist you through the appeal procedure. The member advocate will advise you or your authorized representative of the disposition of the appeal and the action taken. To learn more about your appeal rights, click here.
How to file a Standard Appeal:
If you disagree with our decision to deny or partially deny a request for payment, a request for service or course of treatment, you are entitled to a full and fair review by individual associated with us, but not involved in making the initial decision.
You or your authorized personal representative may file an appeal by submitting a written request within 180 days following receipt of a notification of an adverse benefit determination. If you fail to submit your appeal within the 180 day timeframe, you lose your right to appeal. You may provide us with additional information that relates to your claim or request for service and you may request or receive copies of information we used to make the initial denial, including the diagnosis and treatment codes and their corresponding meaning, free of charge.
If you wish to authorize another person, including an attorney, to act on your behalf, and with whom you want us to communicate, we require your authorization in writing. You may use our Personal Representative Appointment and Authorization to Release Protected Health Information Form or you can provide us with your own written expression of authorization and include it with your written appeal request. Representation is not required and you are not required to use the form to appoint an authorized representative.
Your written appeal request should include:
- Date of your appeal request;
- Your printed name and address (if you designated an authorized representative, the and address of your authorized representative);
- Your Gundersen Health Plan identification number (from your Gundersen Health Plan identification card);
- Any information or documents to support your appeal request; and
- Your signature.
Send your written appeal request with all supporting information to:
Gundersen Health Plan
1900 South Avenue NCA2-01
La Crosse, WI 54601
Fax: (608) 775-8060
For appeals involving a medically urgent situation, you may request an expedited appeal, either orally or in writing. Expedited appeals will be conducted as expeditiously as your health condition requires but no later than 72 hours from the date we receive the request for an expedited appeal. Expedited appeal means a situation where (1) the duration of the standard appeal process could seriously jeopardize your life or health or your ability regain maximum function; (2) in the opinion of your physician; you may experience severe pain that cannot be adequately controlled without the care or treatment, and (3) your physician requests an expedited appeal.
If you believe your situation is urgent, you may request an expedited appeal by following the instructions for a standard internal appeal or by telephone at (608) 775-8052 or (800) 897-1923, extension 58052. You may also file a request for an expedited external review at the same time as the internal appeal process for urgent care situations and ongoing course of treatment. To learn more about the external review process in Iowa, please reference Section 7 - Appeal & External Review Procedures of your Certificate of Coverage.
External Review Rights
In addition to your right to file a complaint or appeal concerning your claim or benefit denial, you or someone you name to act for you (your authorized representative) may also be entitled to an external review by medical professionals who have no connection to Gundersen Health Plan to address your concerns. External reviews are conducted by independent review organizations (IROs) that are assigned by the Iowa Insurance Commissioner. The assignment of the IRO will be done on a rotation among a list of approved IROs maintained by the Iowa Insurance Commissioner.
Covered persons enrolled in a self-funded health plan should check their plan documents or contact Gundersen Health Plan to find out if this program or any external review process is available to them.
When can you request an external review?
If Gundersen Health Plan denied your request for payment or health care service or course of treatment or you did not receive a decision within 30 days following the date you or your authorized representative file an appeal of an adverse determination, you may have the right to request an external review.
You must first exhaust Gundersen Health Plan’s internal appeal process before you can initiate an external review. You may obtain an external review if the decision involved:
- The admission, availability of care, continued stay, or other health care service that is a covered benefit;
- The denial reduction or termination of payment for a service because we determined it did not meet the requirements for medical necessity, health care setting, level of care or effectiveness of the health care service or treatment requested;
- The decision was based on a determination that the service or treatment in investigational or experimental; or
- Upon agreement by us to waive your request for exhaustion of the internal grievance process requirement. If waived, you or your authorized representative may file a request in writing for a standard external review.
You may be entitled to an expedited independent review if:
- You have a medical condition that would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function if treatment is delayed,
- The final adverse determination concerns an admission, availability of care, continued stay, or a health care service which you received emergency services, but have not been discharged from a facility; or
- The denial to provide or pay for a health care service or a course of treatment is based on the determination that the service or treatment is experimental or investigational and if your treating physician certifies in writing that delaying the service or treatment would render it significantly less effective, you may also have the right to request an expedited external review.
You do not need to complete the internal appeal process if you need immediate medical treatment and the time period for completing the appeal process will cause a delay that could jeopardize your life or health.
How do you file a request for external review?
External review may be requested from the Iowa Insurance Division. You can obtain a copy of the External Review Request Form from the Iowa Insurance Division at 330 Maple Street, Des Moines, IA 50319, telephone 877-955-1212 or 515-281-6348; facsimile 515-281-3059 or www.iid.state.ia.us You must submit your request for external review to the Iowa Insurance Division within four months after our notice containing the final adverse decision. External review is not available to all members or in all cases. Self-funded group health plans may use a different external review process.
What if I have more questions about the external review process?
To learn more about the external review process in Iowa, please review the fact sheet on Important Information about Your Rights to External Review or reference Section 7 – Appeal & External Review Procedures of your Certificate of Coverage. This section contains valuable information regarding the external review process.
Information regarding your external review eligibility may also be obtained from the Iowa Insurance Division at (515) 282-4227 or if you have questions on how to request an external review, contact our member advocate at (608) 775-8052 or toll-free at (800) 897-1923, extension 58052.
If you require language assistance at no cost to you, please call Customer Service at (608) 775-8007 or toll-free at (800) 897-1923. For people who are deaf, hard of hearing or speech impaired, please call TTY 711 or toll free 800-877-8973 or you may call through a video relay service company of your choice. Interpreter services are provided free of charge to you.