A complaint is any expression of dissatisfaction expressed to us by the member, or a member's authorized representative, about us or our providers with whom We have a direct or indirect contract. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner.
lf you have a complaint, please contact our Customer Care Center at 833-942-2159. We will document and investigate your complaint and notify you of the outcome. lf your complaint is not resolved to your satisfaction you, your health care provider, or your authorized representative may file a grievance.
A grievance is any written complaint submitted by or on behalf of a member expressing dissatisfaction with Us, including:
An Adverse Determination is a denial, reduction, or termination of benefits because the care does not meet Our definition of medical necessity, appropriateness, health care setting, level of care or effectiveness.
To file a grievance, you or your authorized representative must send your grievance to us in writing within 180 days of the original Adverse Determination at the following address:
Attention: Grievance and Appeal Department
P.O. Box 56099
Madison, WI 53705
We will not charge you for filing a grievance with us. you will have continued coverage under this insurance policy pending the outcome of an internal appeal. This applies for covered services only. When we receive your grievance, our Grievance and Appeal Department will send you an acknowledgement letter within five business days. Our acknowledgment letter will advise you of:
If you choose to meet with the Grievance and Appeal Committee you may do so either in person or over the phone via teleconference. As described in the acknowledgement letter, you must call and schedule a meeting time.
The Grievance and Appeal Committee will consist of:
Your grievance will be documented and investigated. So that you have time to respond prior to Our grievance decision, We will automatically send you the following information:
At any time if you wish to receive a free copy of any other documents relevant to the outcome of your grievance, send a written request to the address listed above. All grievances will be resolved within 30 calendar days from the day We receive your request. You have the right to bring a civil action under section 502 of ERISA following an Adverse Benefit Determination on review (Our grievance decision).
lf We decide your grievance is urgent according to Our criteria, We will resolve your grievance within 72 hours of the time when We receive it. Our criteria are based on the expedited grievance provisions of applicable law.
We will automatically treat your grievance as expedited if:
You, Your authorized representative or Your Health Care Provider may request an expedited grievance either orally at 608-828-1991, by fax at 608-252-0812, or in writing at WellFirst Health, Attention: Grievance and Appeal Department, P.O. Box 56099, Madison, WI 53705. You can make this request in your initial grievance or in a separate communication.
lf you are eligible for an expedited internal grievance and also for external review, you can request that your internal and external reviews happen at the same time. You have the right to bring a civil action under section 502 of ERISA following an Adverse Benefit Determination on review (Our grievance decision).
You may also be entitled to an independent external review (IER). You can ask for an external review if We denied your grievance and it involves care that We have determined does not meet the policy requirements for reasons involving medical judgement. Those reasons include, but are not limited to:
You can also request an external review if your requested services are considered Experimental or Investigational or if we have rescinded your policy, whether you or a Qualified Dependent is entitled to a reasonable alternative standard for a reward under a wellness program, or whether we are complying with the non-quantitative treatment limitation provisions of mental health parity requirements.
You must exhaust our internal review process before you can request an external review, unless:
If you or your authorized representative wishes to request an external review, you or your authorized representative must submit your request within four months of the date We decided your grievance. There are two categories of external review, standard and expedited. Most requests for external review will follow the standard timeline; however in some cases you may ask for an expedited (faster) review.
You may request a standard external review in one of the following ways:
If you choose to mail or fax your request, print and fill out the online form. Note: you may also provide additional documentation such as:
You can get the online form at externalappeal.cms.gov or by calling our Customer Care Center at 833-942-2159 (TTY: 711).
The IRO will notify you and us of its decision no later than 45 days after it receives your request for external review.
A decision made by the IRO is binding for both you (the Member) and Usm. You are not responsible for the costs associated with the IER.
In some cases you may ask for an expedited (faster than usual) external review. You may request an expedited external review when:
You may request an expedited external review by following the process described above for standard external reviews, or by calling the IRO at 888-866-6205. The 72 hour time frame for an expedited review request begins when the phone call ends.
The IRO will notify you and us of its decision as soon as possible, but no later than 72 hours after it receives your request for external review. The IRO may call you with its decision, but it must also mail you a written version of the decision within 48 hours of calling you.
A decision made by the IRO is binding for both Us and the Member. You are not responsible for the costs associated with the IER.
You may resolve your problem by taking the steps outlined above. You may also contact the Employee Benefits Security Administrator of the U.S. Department of Labor and file a complaint.
You may file a complaint online at:
You may also request a complaint form by calling 866-444-3272 or by writing to:
U.S. Department of Labor
Employee Benefits Security Administration
200 Constitution Ave., NW
Washington, DC 20210
At times you may have questions and concerns about benefits, claims or services you receive from WellFirst Health. Sharing your concerns will help us to identify our strengths and weaknesses.
When a question or concern arises, we encourage you to reach out to our Customer Care Center at 833-942-2159. Our customer care specialists will make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care.