What is an appeal?
You have a right to request an appeal if you are unhappy with a decision made by iCare. An appeal is a request for iCare to review a decision that affects your services. These decisions are called adverse benefit determinations.
An adverse benefit determination is any of the following:
- iCare plans to stop, suspend, or reduce a service you are currently getting.
- iCare decides to deny a service you asked for.
- iCare decides not to pay for a service.
- iCare asks you to pay an amount that you don’t believe you owe.
- iCare decides to deny your request to get a service from a non-network provider when you live in a rural area that has only one HMO.
- iCare does not arrange or provide services in a timely manner.
- iCare does not meet the required timeframes to resolve your grievance or appeal.
iCare will send you a letter if you have received an adverse benefit determination.
Who can file an appeal?
You can request an appeal. An authorized representative, a legal decision maker, or a provider can also file an appeal for you. We will contact you for your permission if an authorized representative or provider requests an appeal for you.
When can I file an appeal?
You (or your representative) must request an appeal within 60 days of the date on the letter you get describing the adverse benefit determination.
How do I file an appeal with iCare?
If you would like to appeal an adverse benefit determination, you can call the iCare Member Advocate at 1-800-777-4376 or write to the following address:
Independent Health Care Plan
1555 North RiverCenter Drive, Suite 206
Milwaukee, Wisconsin 53212
If you request an appeal with iCare, you will have the opportunity to appeal in-person in front of iCare’s Grievance and Appeal Committee. Once your appeal is requested, iCare will have 30 calendar days to give you a decision.
What if I can’t wait 30 days for a decision?
If you or your doctor think that waiting 30 days could seriously harm your health or ability to perform your daily activities, you can request a fast appeal. If iCare agrees that you need a fast appeal, you will get a decision within 72 hours.
Who can help me request an appeal?
If you need help writing a request for an appeal, please call your iCare Member Advocate at 1-800-777-4376.
If you want to speak with someone outside iCare, you can call the BadgerCare Plus and Medicaid SSI Ombuds at 800-760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at 1-800-708-3034 for help with your appeal.
Can I continue to get the service during my appeal?
If iCare decides to stop, suspend, or reduce a service you are currently getting, you have the right to ask to keep getting your service during your appeal. You’ll have to mail, fax, or email your request within a certain timeframe, whichever is later:
- On or before the date iCare plans to stop or reduce your service.
- Within 10 days of getting notice that your service will be reduced.
If iCare’s decision about your appeal is not in your favor, you might have to pay iCare back for the service you got during the appeal process.
Will I be treated differently if I request an appeal?
You will not be treated differently from other members because you request an appeal. The quality of your health care and other benefits will not be affected.
What if I disagree with iCare’s decision about my appeal?
You can request a fair hearing with the Wisconsin Division of Hearing and Appeals if you disagree with iCare’s decision about your appeal. Learn more about fair hearings below.
What Happens Next
Within 30 calendar days of receiving your appeal (or an additional 14 days if there has been an extension), iCare will make a decision about your appeal and you will receive written notice of our decision. If we determine we made an incorrect decision, iCare will authorize the services. If we determine we were correct to deny your services, you can then ask for a State Fair Hearing.
Fair Hearing
What is a fair hearing?
A fair hearing is a review of iCare’s decision on your appeal by an Administrative Law Judge in the county where you live. You must appeal to iCare first before requesting a fair hearing.
When can I request a fair hearing?
You must request a fair hearing within 90 days of the date you get iCare’s written decision about your appeal.
How do I request a fair hearing?
If you want a fair hearing, send a written request to:
Department of Administration
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707-7875
You have the right to be represented at the hearing, and you can bring a friend for support. If you need a special arrangement for a disability or for language translation, please call 1-608-266-7709.
Who can help me request a fair hearing?
If you need help writing a request for a fair hearing, please call the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at 1-800-708-3034 for help.
Can I keep getting the service during my fair hearing?
If iCare decides to stop, suspend, or reduce a service you are currently getting, you have the right to ask to keep getting your service during your iCare appeal and fair hearing. You’ll have to request that the service continue during your fair hearing, even if you already requested to continue the service during your iCare appeal. You’ll have to mail, fax, or email your request within a certain timeframe, whichever is later:
- On or before the date iCare plans to stop or reduce your service.
- Within 10 days of getting notice that your service will be reduced.
If the administrative law judge’s decision is not in your favor, you might have to pay iCare back for the service you got during the appeal process.
Will I be treated differently if I request a fair hearing?
You will not be treated differently from other members because you request a fair hearing. The quality of your health care and other benefits will not be affected.
Help with Understanding Your Rights, or Help with Filing a Grievance or Appeal
iCare has a Member Advocate that can help you understand your rights and/or help you file a grievance or appeal. The iCare Member Advocate contact information is below:
Member Advocate
Independent Care Health Plan
1555 North RiverCenter Dr., Suite 206
Milwaukee, WI 53212
Phone: 414-231-1076
Toll Free: 800-777-4376
TTY: 800-947-3529
Fax: 414-231-1090
E-mail: advocate@iCareHealthPlan.org
You may also contact the following resources for information or assistance: