Family Care Partnership Appeals

iCare Family Care Partnership Appeals

If you are asking to appeal a decision for your Family Care Partnership benefits, an appeal request can be made either orally or in writing. An oral filing must be followed up with a written request. verbal or written requests must be received within 45 calendar days from the date of the denial letter.

Two types of Appeals:

Standard: Standard appeal decisions are made no later than 20 business days from receiving the request for an appeal. Independent Care may extend the timeframe up to 10 business days if you request the extension or if iCare is able to justify that an extension is in your best interest.

Standard appeals must be submitted within 45 calendar days from the date on the denial notice by writing to:

  • Quality Improvement Specialist
  • Independent Care Health Plan
  • 1555 N. RiverCenter Dr. Ste. 206
  • Milwaukee, WI 53212-3958

iCare Member Rights Specialist can inform you of your rights, attempt to informally resolve your concern, and assist you with filing an appeal. He or she cannot represent you at a State fair hearing. To contact our iCare’s Member Rights Specialist, call 414-231-1076.

The following independent ombudsman agencies may be able to provide you with free assistance. These agencies advocate for Family Care Partnership members.

  • For members age 18 to 59:
  • Disability Rights Wisconsin Family Care and IRIS Ombudsman Program
  • Call the office closest to you:
    • Toll Free Madison: (800) 928-8778
    • Milwaukee: (800) 708-3034
    • Rice Lake: (877) 338-3724
    • TTY (888) 758-6049
  • For members age 60 and older:
  • Wisconsin Board on Aging and Long Term Care
  • Toll Free (800) 815-0015

What Happens Next?

  • Step 1: Within 10 business days you will receive an acknowledgment letter confirming your appeal has been received
  • Step 2: Within 20 business days of receiving your appeal iCare will investigate and make all reasonable efforts to gather additional information relevant to your appeal
  • Step 3: An Appeal Committee meeting is scheduled. Members are encouraged to attend the appeal meeting and speak with the Committee
  • Step 4: After the committee reviews all of the information, and speaks to the member, a decision is made to either approve or deny the benefit
  • Step 5: If the Committee determines to approve the service, iCare will authorize the service in dispute
  • Step 6: If the committee determines to deny the benefit, you can ask the state to review the denial or request a Fair Hearing

Department of Health Services Review

You may also choose to have this decision reviewed by MetaStar, the Department of Health Services’ external quality review organization. MetaStar will try to resolve your concerns informally. You can request to have your services continued during the review, if you request the review on or before the effective date of the intended action. If you request a state fair hearing, MetaStar will automatically review your appeal. Please note, however, that MetaStar cannot require any MCO to change its decision.

To request that MetaStar review your case immediately or to learn more about a MetaStar review, call 1-888-203-8338. You may also request a MetaStar review by mail, fax, or email.

  • DHS Family Care and Partnership Grievances, C/O MetaStar
  • 2909 Landmark Place
  • Madison, WI 53713
  • Fax: (608) 274-8340
  • E-mail MetaStar at

You could also choose to request a fair hearing with the State of Wisconsin’s Division of Hearings and Appeals, you will have a hearing with an independent judge. You may bring an advocate, friend, family member or witnesses. You may also present evidence at this hearing. If you request a State Fair Hearing, your appeal will automatically go through a Department of Health Services review.

To file a request for a fair hearing, you can ask for a hearing and/or a hearing form from the Member Rights Specialist at 414-231-1076. You can also request a hearing form from one of the independent ombudsman agencies listed or you can go online and get a form at:
http://dhs.wisconsin.gov/forms/f0/f00236.doc

You can send the completed request form or a letter asking for a hearing and a copy of this notice to:

  • Family Care Request for Fair Hearing, c/o Wisconsin Division of Hearings and Appeals
  • 5005 University Ave. #201
  • Madison, WI 53705-5400
  • or
  • Fax: 608-264-9885

Expedited (fast) Appeal: You can ask for an expedited appeal if you feel your health could be in jeopardy by waiting the standard timeframe. Expedited appeals are decided within two business days. Expedited appeals can be transferred to the standard timeframe if it is determined your life is not in serious jeopardy.

Expedited appeals follow the same steps as a standard appeal, however the process will be completed within 72 hours from receiving the appeal request.


Modified: 2/21/2018

H2237_IC1770 Pending CMS Approval

 

The iCare Family Care Partnership (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in iCare Family Care Partnership depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare and functionally eligible as determined by the State of Wisconsin Long-Term Care Functional Screen. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Part B premium is covered by the State if you are a full-dual member. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must receive all routine care from plan providers. For more information about Medicare benefits and services, including general information regarding the health or Part D benefit, contact 1-800-MEDICARE (1-800-633-4227) or visit http://www.medicare.gov; TTY users should call 1-887-486-2048, 24 hours a day, 7 days a week. For more information about State Medicaid benefits call the Department of Health Services at 1-800-362-3002 (TTY 1-888-701-1251) or visit http://dhs.wisconsin.gov/medicaid. For more information about long-term care options available to you in your county contact the Aging and Disability Resource Centers. The Resource Center can also assist you with information about eligibility and enrollment.

  • H2237_IC1770 CMS Approval
 
  • Independent Care Health Plan
  • 1555 RiverCenter Drive, Suite 206
  • Milwaukee, WI 53212
  • Customer Service: 1-800-777-4376
    • 24 hours-a-day, 7 days-a-week
    • (Office Hours: Monday-Friday, 8:30 a.m. to 5:00 p.m.)
  • TTY: 1-800-947-3529
  • Fax: 414-231-1092
  • All content and images unless otherwise indicated are
  • Copyright © 2018 Independent Care Health Plan