Grievance and appeals

Medical grievances and appeals

We know that at times you may have questions and concerns about benefits, claims or services you have received from WellFirst Health — Provided by SSM Health Plan. When a question or concern arises, we encourage you to reach out to our Customer Care Center at 1-866-514-4194. Our Customer Care specialists will make every effort to resolve your concern promptly and completely.

If, after contacting us, you continue to feel the decision has adversely affected your coverage, benefits, or relationship with us, you or your authorized representative may file a written grievance. You, your health care provider, or your authorized representative also have the right to file a verbal or written appeal.

Grievance

A Grievance is any written complaint submitted to us by or on behalf of an enrollee regarding any aspect of the Plan. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner. Your grievance will be documented and investigated.

You will have the right to meet with the Grievance and Appeals Committee regarding your grievance. Within 60 calendar days after the receipt of the written grievance the Grievance and Appeals Committee will render a determination. We will mail written notification of the determination of the Grievance and Appeals Committee to you within 5 business days following the determination.

We will not charge you for filing a grievance with us. To file a grievance, you or your authorized representative must send your grievance, to us in writing at the following address:

WellFirst Health — Provided by SSM Health Plan
Attention: Grievance and Appeal Department
P.O. Box 56099
Madison, WI 53705

Appeal

An Appeal is a verbal or 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, (d) reimbursement for health care services, (e) availability, delivery, or quality of health care services.

You, your authorized representative or your health care provider may request an appeal either orally at 1-866-514-4194, by fax at 608-252-0812, or in writing at the address listed above. The provider and member each have the right to file an appeal one time each for the adverse benefit determination.

When we receive your appeal, the Grievance and Appeal Department will send you an acknowledgement letter within 3 business days. Our acknowledgment letter will advise you of:

  • All information we need to evaluate the appeal;
  • Your right to submit written comments, documents or other information regarding your appeal;
  • Your right to request additional information;
  • Your right to be assisted or represented by another person of your choosing, including an attorney; and
  • Your right to appear before the Grievance and Appeal Committee.


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.

Your appeal will be documented and investigated. So that you will have time to respond prior to our appeal decision, 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 appeal; or
  2. Any new or additional rationale we use to make our decision.


We will complete the investigation and a decision will be made within 15 business from the receipt date of the required information, but no greater than 30 calendar days of the original receipt date.

Pursuant to the Health Carrier External Review Act you also have the right to:

  1. Bypass the internal standard appeals process and file an expedited review for urgent situations
  2. Bypass the internal appeals process if we fail to comply with internal claims and appeals requirements and timeframes
  3. File an expedited external review at the same time as the internal expedited appeal


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

Expedited appeal

If your situation meets the definition of an Expedited Appeal, we will resolve the appeal on an expedited basis.

Upon the receipt of an expedited pre-service or concurrent clinical appeal, we will notify the party filing the appeal as soon as possible, but in no event more than 24 hours after the submission of the appeal, of all the information needed to review the appeal. We will render a decision on the hours after we receive the requested information, but in no event more than 48 hours received the appeal. For the ongoing course of treatment, coverage will continue during the appeal. We will automatically treat your appeal as expedited if:

  1. Your concerns are related to a ongoing courses of treatment, 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 appeal either orally at 608-828-1991, by fax at 608-252-0812 or in writing at the address listed in the sections above.

lf you are eligible for an expedited internal appeal and also for an expedited external review, you can request that your internal and external reviews happen at the same time. You can make this request in your initial appeal or in a separate communication.

External review

You or your authorized representative have the right to request a Standard or an Expedited External Review. The timeframes for filing an external review are not postponed or delayed by health care provider appeals, unless your health care provider is acting as your authorized representative .

Standard external review

You or your authorized representative must submit a written request for a standard external review to the Illinois Department of Insurance (“IDOI”) within four (4) months of receiving an adverse determination or final adverse determination. You or your authorized representative may fill out the enclosed External Review Form. our request should be submitted to the IDOI at the following address:

Illinois Departments of Insurance
Office of Consumer Health Insurance, External Review Unit
320 W. Washington Street
Springfield, IL 62767
(877) 850-4740 Toll-free phone
(217) 557-8495 Fax number
[email protected] Email address
https://mc.insurance.illinois.gov/messagecenter.nsf

The following Illinois Department of Insurance forms can be found at:

Request for External Review
https://insurance.illinois.gov/ExternalReview/ExternalReview.pdf

Physician Certification Expedited Review
https://insurance.illinois.gov/ExternalReview/PhysicianCertificationExpeditedReview.pdf

Physician Certification Experimental/Investigational Review
https://insurance.illinois.gov/ExternalReview/PhysicianCertificationExperimentalInvestigationalReview.pdf

The Director will notify us within 1 business day of receipt of standard external review request.

We will complete a preliminary review and determine the following; (a) You were covered by the health plan at the time the services were requested or provided (b) the service is a covered service, however, determined the health care service is not covered (c) the internal appeals procedures have been exhausted unless not required pursuant to the Illinois Health Carrier External Review Act; and (d) all the necessary information has been provided to process the external review.

Within one business day following the preliminary review, we will notify the director whether the request is complete and eligible for external review. If the request is not eligible, we will notify the director and the member in writing, to include what information is required to make the request eligible for external review. This notice will include the right to appeal the ineligibility determination with the director.

a. If you or your authorized representative submit an appeal to the director, the director may determine that the request is eligible for external review and require that it be referred to the IRO. The director will notify us of the determination and the assigned IRO.

When a request is deemed eligible for external review, the director will within one business following receipt of notice, assign an IRO. The director will notify us and you or your authorized representative of the assigned IRO.

You or your authorized representative will be advised of the right to submit additional information to the IRO within five business days of receipt of the notice. If additional information is submitted by the member, we will provide this information to the IRO within five business days.

If the IRO receives additional information, the IRO will provide the information to us within one business day of receipt. We may reconsider the original adverse determination. Reconsideration, however, will not delay or terminate the external review process. The external review may only be terminated if we reverse the original adverse determination. In this event, we will provide written notice to the director, you, your authorized representative, and the IRO within one business of the decision.

Within five calendar days following receipt of all the necessary information, but not greater than 45 calendar days, the IRO will provide written notice of the final determination to the director, us and you or your authorized representative.

Upon receipt of the written determination overturning the original adverse determination, we must approve the coverage immediately.

Expedited external review

Expedited requests follow the procedures outlined above, however, at an escalated pace. Notifications must be made immediately rather than in 1 business day or as otherwise defined for the standard review. The final IRO determination must be made and communicated within 72 hours, rather than 45 calendar days.

Illinois Department of Insurance

You may resolve your problem by taking the steps outlined above. You may also contact the Illinois Department of Insurance, a state agency which enforces Illinois’ insurance laws and file a complaint.

The Illinois Department of Insurance
Office of Consumer Health Insurance
320 West Washington Street
Springfield, IL 62767

Non-formulary grievances and appeals rights

We know that at times you may have questions and concerns about benefits, claims or services you have received from WellFirst Health — Provided by SSM Health Plan. When a question or concern arises, we encourage you to reach out to our Customer Care Center at 1-866-514-4194. Our Customer Care Specialists will make every effort to resolve your concern promptly and completely.

If, after contacting us, you continue to feel the decision has adversely affected your coverage, benefits, or relationship with us, you or your authorized represented may file a written grievance. You, your health care provider, or your authorized representative also have the right to file a verbal or written appeal.

Grievance

A Grievance is any written complaint submitted to us by or on behalf of an enrollee regarding any aspect of the Plan. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner. Your grievance will be documented and investigated.

You will have the right to meet with the Grievance and Appeals Committee regarding your grievance. Within 60 calendar days after the receipt of the written grievance the grievance and Appeals Committee will render a determination. We will mail written notification of the determination of the Grievance and Appeals Committee to you within 5 business days following the determination.

This grievance 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.

We will not charge you for filing a grievance with us. To file a grievance, you or your authorized representative must send your grievance, to us in writing at the following address:

Attention: WellFirst Health — Provided by SSM Health Plan — Grievance and Appeal Department
P.O. Box 56099
Madison, WI 53705
 

Non-formulary exception appeal

If you or your prescribing health care provider wish to appeal a denied non-formulary exception to coverage request you may do so orally at 608-828-1991, by fax at 608-252-0812, or in writing at the address listed above or orally at the phone number listed above. The provider and member each have the right to appeal one time each for the adverse benefit determination.

Standard non-formulary exception

If your request is not urgent we will follow our standard non-formulary exception appeal timeline.

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 appeal 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.

Expedited non-formulary exception

An expedited review is available under the following circumstances:

  • If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug you, your prescriber or your authorized representative may be able to ask for an urgent review process; or
  • If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current drug therapy uses a non-covered drug you, your prescriber or your authorized representative may be able to ask for an urgent review process.

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 appeal process, we will cover the drug for the duration of the exigency during an expedited exception appeal process. If we approve your appeal, we will cover the drug until your prescription expires, including refills.

External review

If we deny your standard or expedited non-formulary exception appeal, you, your authorized representative, or your prescribing health care provider have the right to request a Standard or an Expedited External Review. The timeframes for filing an external review are not postponed or delayed by health care provider appeals, unless your health care provider is acting as your authorized representative.

You or your authorized representative must submit a written request for an external review to the Illinois Department of Insurance (“IDOI”) within four (4) months of receiving an adverse determination or final adverse determination. You or your authorized representative may fill out the enclosed External Review Form. Your request should be submitted to the IDOI at the following address:

Illinois Departments of Insurance
Office of Consumer Health Insurance External Review Unit
320 W. Washington Street
Springfield, IL 62767

(877) 850-4740 Toll-free phone
(217) 557-8495 Fax number
[email protected] Email address
https://mc.insurance.illinois.gov/messagecenter.nsf

The Illinois Department of Insurance Request for External Review form can also be found at: https://insurance.illinois.gov/ExternalReview/ExternalReview.pdf

Illinois Department of Insurance

You may resolve your problem by taking the steps outlined above. You may also contact the Illinois Department of Insurance, a state agency which enforces Illinois’ insurance laws and file a complaint.

The Illinois Department of Insurance
Office of Consumer Health Insurance
320 West Washington Street
Springfield, IL 62767