STATE OF WISCONSIN
COMPLAINT, GRIEVANCE AND INDEPENDENT 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 (800) 362-3310.
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/TDD 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. Customer Service is available to assist you Monday through Friday from 8 a.m. to 5 p.m.
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 grievance to the Appeals Specialist. The Appeals Specialist is an individual employed by us specializing in the grievance process. The Appeals Specialist will receive and record your written grievance and will have your grievance investigated by the appropriate staff and assist you through the grievance procedure. The Appeals Specialist will advise you or your authorized representative of the disposition of the grievance and the action taken. To learn more about your grievance rights click here.
How to file a Standard Grievance
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 individuals associated with us, but not involved in making the initial decision.
There is no time limitation to file a written grievance. 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 provide us with your own expression of authorization and include with your written grievance request. Representation is not required and you are not required to use the form to appoint an authorized representative.
Your written grievance request should include:
- Date of your grievance request;
- Your printed name and address (if you designated an authorized representative, the name 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 grievance request; and
- Your signature.
Send your written grievance request with all supporting information to:
840 Carolina St.
Sauk City, WI 53583
Fax: (608) 644-3500
How to file an Expedited Grievance
For grievances involving a medically urgent situation, you may request an expedited grievance, either orally or in writing. To request an expedited grievance please call Appeals Specialists at (800) 362-3309 extension 101901, or in writing to the above referenced address.
Expedited grievance means a situation where: 1) the duration of the standard grievance 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 grievance.
If you believe your situation is urgent, you may request an expedited grievance by following the instructions for a standard internal grievance or by telephone. You may also file a request for an expedited external review at the same time as the internal grievance process for urgent care situations and ongoing course of treatment.
Independent Review Rights
In addition to your right to file a complaint or grievance concerning your claim or benefit denial, you or someone you name to act for you (your authorized representative) may also be entitled to an independent review by medical professionals who have no connection to Gundersen Health Plan to address your concerns.
The independent review process offers members the opportunity to have certain coverage denials reviewed by independent physician reviewers. The Appeals Specialist will refer the request to an independent review organization (IRO) contracted with Gundersen Health Plan. The IRO will assign your dispute to a clinical reviewer who is an expert in the treatment of your medical condition. The IRO is responsible for choosing a physician who is board certified in the area of medical specialty at issue in the case. The physician reviewer must take an evidence-based approach to reviewing the coverage determination, and must follow the Plan’s documents and applicable criteria governing your benefits.
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.
When can you request an independent external review?
If Gundersen Health Plan denied your request for payment, health care services or course of treatment, or you did not receive a decision within 30 days following the date you or your authorized representative filed a grievance of an adverse benefit determination, you may have the right to request an independent external review.
Typically, you must first exhaust Gundersen Health Plan’s internal grievance process before you can initiate an independent external review. You may obtain an independent 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;
- Rescission of health insurance policy or certificate;
- The denial of coverage or treatment was on the basis of preexisting condition exclusion;
- The decision was based on a determination that the service or treatment is 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 external 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 decision was based on a determination that the service or treatment is investigational or experimental.
You do not need to complete the internal grievance process if you need immediate medical treatment and the time period for completing the grievance process will cause a delay that could jeopardize your life or health, or we agree with you that it is in everyone's best interest to proceed with your concern directly to independent review.
How do you file a request for independent external review?
To file a request for independent review, you will need to complete an External Review Request Form. To obtain an External Review Request Form click here or call the Appeals Specialists at (800) 362-3309 extension 101901. You must submit your request for independent external review to Gundersen Health Plan’s Appeals Specialist within four months (120 days) after our notice containing the final adverse decision.
Is there a cost involved for external review?
There is no cost for requesting an independent review and you will not be responsible to bear the cost of the review conducted by the IRO.
How long does the external review process take?
After all the necessary information is submitted, external reviews generally will be decided within forty-five (45) days after the date of request of an eligible request for independent external review, and within 72 hours of an eligible expedited review. The IRO will provide written notification of its decision to you, your authorized representative, and Gundersen Health Plan.
If the IRO overturns the initial adverse benefit determination, Gundersen Health Plan must abide by the decision and will immediately provide coverage or payment for the health care service or treatment. The decision of the IRO is binding.
What if I have more questions on the independent review process?
To learn more about independent external review process in Wisconsin, please review the fact sheet on Important Informatoin about Your Rights to Independent Review, reference Section 7 – Grievance & Independent Review Procedures of your Certificate of Coverage as this section contains valuable information regarding the independent review process in Wisconsin, or contact the Appeals Specialists at (800) 362-3309 extension 101901.
If you require language assistance at no cost to you, please call Customer Service at (800) 362-3310. For people who are deaf, hard of hearing or speech impaired, please call TTY/TDD 711 or you may call through a video relay service company of your choice.
Additional information on the federal external review process may be found from the U.S. Department of Health and Human Services at The Center for Consumer Information & Insurance Oversight’s web site at: http://cciio.cms.gov/programs/consumer/appeals/index.html.
You may also contact the State of Wisconsin, Office of the Commissioner of Insurance, by telephone at (608) 266-0103 (Madison) or (800) 236-8517 (Statewide).