Grievance and appeals

lf you have a complaint, please contact our Customer Care Center. 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/appeal.

Grievance/Appeal

A written complaint submitted by or on behalf of a member expressing dissatisfaction with us, including:

a.    The way We provide services or process claims.
b.    A decision to change or rescind a policy.
c.    An Adverse Determination made by Utilization Management to include Medically Necessary pharmaceutical prescriptions and durable medical equipment.
d.    Reimbursement for health care services.
e.    Availability, delivery, or quality of health care services.
f.    Matters pertaining to the contractual relationship between a Member and Us.

Under Missouri law, an Adverse Determination is a determination by Us that an admission, availability of care, continued stay or other health care service furnished or proposed to be furnished to a Member has been reviewed and, based upon the information provided, does not meet Our requirements for Medical Necessity, appropriateness, health care setting, level of care or effectiveness, or are experimental or investigational, and the payment for the requested service is therefore denied, reduced or terminated.

This grievance/appeal process does not apply when a Member is requesting coverage of a drug or item not listed on Our formulary. These requests are subject to the non-formulary exception process described later in this section.

To file a grievance/appeal, you or your authorized representative must send your grievance/appeal, to Us in writing at the following address:

WellFirst Health
Attention: Grievance and Appeal Department
P.O. Box 56099 Madison, WI 53705

2024 Individual and Marketplace plans: To file a grievance/appeal, you or your authorized representative must send your grievance/appeal, to Us in writing at the following address:

Medica
Route CP595IFB
P.O. Box 9310
Minneapolis, MN  55440-9310
Fax: 952-992-3198

We will not charge you for filing a grievance/appeal with Us. When We receive your grievance/appeal, Our Grievance and Appeal Department will acknowledge receipt in writing of the grievance/appeal within 10 working days. Our acknowledgment letter will advise you of:

• Your right to submit written comments, documents or other information regarding your grievance/appeal;
• Your right to be assisted or represented by another person of your choosing;
• Your right to review the grievance/appeal file.

At any time if you wish to receive a free copy of any other documents relevant to the outcome of your grievance/appeal, or non-formulary exception request you can send a written request to the address listed above.

We will complete Our review within 20 working days after receipt of your grievance/appeal. If We are unable to complete the research of your grievance/appeal in this timeframe, We will notify you in writing on or before the 20th working day, and the review will be completed within an additional 30 working days. The notice will include specific reasons why additional time is needed.

We will automatically send you the following information:

1. Any new or additional evidence We consider, rely upon, or generate in the course of considering your grievance/appeal; or
2. Any new or additional rationale We use to make Our decision.

Within five working days of the completion of the review, We will make a decision on the appropriate resolution, and notify you in writing of the decision. If someone other than you filed a grievance/appeal on your behalf, we will notify them in writing within 15 working days after the completion of Our review.

If we deny your grievance/appeal we will notify you of your right to submit the grievance/appeal to the Director of the Missouri Department of Commerce and Insurance (DCI) for review. Your decision to request a review by the DCI will not impact your coverage or benefits with Us.

You may file a grievance/appeal with the DCI at any time in the following ways:

• Submit your grievance/appeal electronically at insurance.mo.gov/consumers/complaints/index.php;
• Fax to 573-526-4898; or
• Mail to P.O. Box 690, Jefferson City, MO 65102-0690.

Following the completion of DCI’s review, the Director may refer your unresolved medical necessity grievance/appeal to the Independent Review Organization (IRO). You, your authorized representative, or Health Care Provider may submit additional information to the DCI which shall be forwarded to the IRO. All additional information should be received by the DCI within 15 working days from the date the DCI mailed the party copies of the information to the IRO. At the DCI’s discretion, additional information which is received past the 15 working day deadline may be submitted to the IRO. Within 20 calendar days after receiving your request, the IRO will complete a review and submit its opinion to the DCI. The IRO may request in writing from the DCI additional time not to exceed five calendar days to complete its review. Within 25 calendar days of receipt of the opinion, the DCI will notify you of the decision, and it will be binding on you and Us. In no event shall the time between the date the IRO receives the request for external review and the date You are notified of the Director’s decision be longer than 45 days.

Expedited Grievance/Appeal

lf We decide your grievance/appeal is urgent according to Our criteria, We will resolve your grievance/appeal within 72 hours from the time We receive it. Our criteria are based on the expedited grievance/appeal provisions of applicable law. For situations involving ongoing course of treatment and/or concurrent review, coverage will continue during the grievance/appeal process.

We will automatically treat your grievance/appeal as expedited if:

1. Your concerns are related to a facility admission or concurrent review of a continued facility stay;
2. Our Medical Director decides your life, health, or ability to regain maximum function could be jeopardized by the standard review timeframe;
3. Your Health Care Provider notifies Us that you would be subject to severe pain that cannot be adequately managed without the services you requested; or
4. Your Health Care Provider notifies Us that he or she has decided you need care urgently.

You, your authorized representative or your Health Care Provider may request an expedited grievance/appeal either orally at (608) 828-1991, by fax at (608) 252-0812 or in writing at the address listed above. You can make this request in your initial grievance/appeal or in a separate communication.

lf you are eligible for an expedited internal grievance/appeal and also for external review, you can request that your internal and external reviews happen at the same time.

If we deny your expedited grievance/appeal we will notify you of your right to submit the grievance/appeal to the Director of the DCI for review. Following the completion of DCI’s review, the Director may refer your unresolved medical necessity grievance/appeal to the Independent Review Organization (IRO).The IRO will complete its review as expeditiously as possible. The DCI will issue its determination to You within 72 hours of the time after receipt of the request. If the notice is not in writing the DCI must provide the written decision within 48 hours after the date of the notice of determination, and the decision will be binding on you and Us.

Non-Formulary Exception

If You or your prescribing Health Care Provider wish to grieve a denied non-formulary exception to coverage request you may do so in writing at the address listed above or orally at the phone number listed above.

Standard Non-Formulary Exception

We will notify you, your authorized representative and your prescribing Health Care Provider of Our decision no later than 72 hours after We receive your request. During the exception to coverage review process, We will cover the Drug for the duration of the prescription during a standard exception request. If We approve your request, We will cover the Drug until your prescription expires, including refills.

If We deny your standard non-formulary exception request, We will provide a written notice that will explain the denial and advise You of Your rights to request an external review from an Independent Review Organization (IRO). The notice will include a toll-free number and address for the DCI.

A decision made by an IRO is binding for both Us and the Member with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the external review.

Expedited Non-Formulary Exception

If you need the requested Drug more urgently, We will follow Our expedited non-formulary request timeline. Our criteria are based on the expedited non-formulary exception provisions of applicable law as listed below:

Urgent circumstances exist 

1. When you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain function, or 
2. You are undergoing a current course of treatment using a non-formulary Drug. When you submit your request, you must indicate that your circumstances are urgent.

We will notify you or your authorized representative and your prescribing Health Care Provider of Our decision no later than 24 hours after We receive your request. During the exception to coverage process, We will cover the Drug for the duration of the exigency during an expedited exception request. If We approve your request, We will cover the Drug until your prescription expires, including refills.

If We deny your standard non-formulary exception request, We will provide a written notice that will explain the denial and advise you of your rights to request an external review from an IRO. The notice will include a toll-free number and address for the DCI.

A decision made by an IRO is binding for both Us and the Member with the exception of the Rescission of a policy or certificate. You are not responsible for the costs associated with the external review.