Submission of denial claim Grievances

From wellcare insurance

A member or provider acting on behalf the member and with the member’s written consent may file a grievance either verbally or in writing within 60 calendar days after the date of the occurrence that initiated the grievance.  A verbal request may be followed up with a written request, but the time frame for resolution begins the date the plan receives the verbal filing.

If the member wishes to appoint another person as their representative, he/she must complete an Appointment of Representative statement. The member and the person who will be representing the member must sign the
statement. This form is located in the Forms section of this manual.

The Plan will ensure that punitive action is not taken against a provider who files a grievance on a
beneficiary’s behalf or supports a member’s grievance. The Plan will make a determination on a grievance within the following time frames:

 Expedited Request: 24 hours
 Standard Request: 30 calendar days

The Plan gives members reasonable assistance in completing forms and other procedural steps, including
but not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter
capability. Members will be provided reasonable opportunity to present evidence and allegations of fact or
law in person as well as in writing.

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Request for Expedited Grievance Determination

The member, member’s representative or a provider may file a request for an expedited grievance determination verbally or in writing. A verbal request can be filed by calling Customer Service. A written request can be mailed or faxed directly to the Grievance Department at:

WellCare Health Plans
Grievance Department
P.O. Box 31384
Tampa, FL 33631-3384
or
Fax: 1-866-388-1769

A determination on the expedited request will be made within 24 hours of receipt of the expedited request.
A request for an expedited grievance determination can be made for complaints related to the Plan’s decisions as follows:
 

 Extends the timeframe to make an organization determination or reconsiderations.
 Refuses to grant a request for an expedited organization or reconsideration.

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Grievances Filed Against a Provider

If a member files a grievance against a provider in reference to the quality of care or service provided, the
Plan will fax and mail a request to the provider for response.

Provider Responsibility

The provider is given 10 business days to respond and submit medical records for review. If a provider has not responded within 10 business days, a second fax and certified letter is sent giving an additional five business days.

Continued failure to respond may result in the provider’s panel being closed to new patients and/or will be
interpreted as an indication that the provider does not disagree with the member’s issue. The case is then
forwarded to the Quality Improvement department for further investigation.

If the provider does respond, the case is referred to a Plan nurse who reviews the medical records to
determine if a possible quality issue exists. If the nurse feels a possible quality issue does exist, the case is
referred to a Plan medical director for review. If he/she determines a quality issue exists, the case is referred to the Quality Improvement department for further investigation. If no quality issue is identified, the case is
entered into the Plan’s database for tracking and trending purposes.

14-Day Extension
Each of the appeal or grievance determination periods noted above may be extended by as many as 14
calendar days, if the member requests an extension or if the Plan justifies a need for additional information and
documents how the extension is in the interest of the member. If an extension is not requested by the member,the Plan will provide the member with written notice of the reason for the delay.

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Request for Standard Pre-Service Determination

If the provider is filing a standard pre-service appeal on a member’s behalf, the provider and member must
complete an Appointment of Representative statement, which can be found in the Forms section of this manual.
The Plan will make a determination and provide notification within 30 calendar days of receipt of the
standard pre-service request.

The provider can request a medication appeal without the necessity of an AOR form to be submitted.

Affirmation of Denial
If the Plan upholds its initial action and/or denial (in whole or in part), it will:

* Submit a written explanation for a final determination with the complete case file to theindependent review entity (IRE) contracted by CMS.
o The IRE must issue a final determination as expeditiously as the member’s health or
condition requires, but no more than 30 calendar days from receipt of the case.
o If the IRE agrees with the Plan, the IRE will notify the member and the Plan and give
the member further appeal rights.

*  Notify the member of the decision to affirm the denial and that the case has been forwarded to
the IRE

If the Plan upholds its initial action and/or denial (in whole or in part) for a medication, it will:

- Notify the member of the decision to uphold the original medication denial orally and in writing.
- Provide the member the appeal rights to submit the next level of appeal to the IRE if they do not
agree with the redetermination decision.


Reversal of Denial

If the Plan overturns its initial action and/or denial, it will notify the member verbally and in writing within
30 calendar days of receipt of the determination request

If the IRE overturns the denial, the IRE notifies the member or representative in writing of the decision.

*  The Plan will also notify the member, member’s representative and provider verbally and in writing
that the services are approved and provide an authorization number within 72 hours, if the
member’s condition warrants it, or no more than 14 calendar days from receipt of the IRE’s
determination.

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What are standard appeal and Expedited appeal

Standard Appeals are for services that have already been rendered or for services that are not emergently or urgently needed.
Expedited Appeals are for circumstances when waiting the standard timeframe for an appeal determination could jeopardize the life or health of the member, or the member’s ability to regain maximum function. Expedited appeals are only used for pre-service appeals. This includes situations where a denial has been issued and member remains on an inpatient unit.

Appeal Request Forms: In this packet, you will find separate forms for requesting a standard appeal (page 2) or an expedited appeal (page 3). Each form contains specific submission guidelines. Use of these forms is not required, but will help ensure prompt resolution.

If you do not use the appeal request forms, you must provide a signed cover letter with the following minimum
information:
 A request for appeal or reconsideration of a denial,
 Your name, address, and phone number;
 The member’s name, DOB, and policy number;
 Dates and types of services requested, and the provider rendering the service;
 Reason that you are requesting appeal or believe denial should be overturned.

Appeal requests that do not contain sufficient information will not be processed.
If you choose not to use the expedited appeal request form and would like to request an expedited appeal, you must clearly communicate in the cover letter that you are requesting expedited status.

Supporting Documentation: All appeal requests should include clinical documentation and other pertinent information that supports the need for the requested service. For examples, see page 2.
 
Submission Deadlines: In most cases, providers have 90 days from the initial notice of denial to file a request for appeal. Please check your denial notice, contract, and provider handbook for details.
 
Appeals Address: The address for submission is on page 2 or 3, depending on type of appeal. Please include the word “Appeals” in the address line for correct routing and prompt resolution.
 
Non Network Providers: If you are not a WellCare/ Harmony network provider- and you have not completed a single
 
case agreement- you must complete and send the Waiver of Liability Form on page 4 in order for your appeal to be processed. This applies only to Medicare members. If you have completed a single case agreement, please include a copy with your appeal.
Appeal Outcomes: An appeal determination letter will be mailed to the appealing party for all processed appeals. We do not take routine verbal requests for status updates.
Claims Appeals: This appeal packet is for appeals of services where authorization was denied or claims were not paid as a result of lack of authorization. If you are seeking to appeal the specific amount that was paid on a claim (that is unrelated to whether the service was authorized), or contest a claim denial for untimely filing, then please address your appeal directly to:WellCare Claims Appeals, P O Box 31372, Tampa, FL 33631-3372. If further authorization is required to effect claims payment, then please use the appropriate address below.

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