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Appeals and Grievances

We want you to let us know right away if you have any questions, grievances or problems with your covered services or the care you receive. In this section, we will explain how you can tell us about these concerns/grievances.

You can make three types of grievances. They are called:

State law allows you to make a grievance if you have any problems with us. The state has also helped to set the rules for making a grievance. The rules include what we must do when we get a grievance. If you file a grievance or an appeal, we must be fair. We cannot disenroll you from our plan or treat you differently.

What is an Appeal?

An appeal is a request you can make when you do not agree with a decision we made about your care. Or it can be made if we take too long to make a care decision. 

You can ask for an appeal:

  • If we deny or limit a service you or your doctor asks us to approve
  • If we reduce, suspend or stop services you’ve been getting that we already approved
  • If we do not pay for the health care services you get
  • If we fail to give services in the required timeframe
  • If we fail to give you a decision in the required timeframe on an appeal you already filed
  • If we don’t agree to let you see a doctor who is not in our network and you live in a rural area or in an area with limited doctors
  • If you don’t agree with a decision we made regarding your medicine
  • We denied your request to dispute a financial liability

You will get a letter from us when any of these actions occur. It is called a "Notice of Adverse Benefit Determination" or "NABD." You can file an appeal if you do not agree with our decision.

You must file your appeal within 60 calendar days from the date on the NABD. You can file your appeal by calling or writing to us. To do so by phone, call Member Services at 1-888-588-9842 (TTY 1-877-247-6272). For standard requests, if you call in your appeal, you must follow up with a written, signed one, within thirty calendar days. Send your written appeal to:

For appeal requests for medical For appeal requests for pharmacy
For appeal requests for medical services:

WellCare of  South Carolina
Attn: Appeals Department
Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368
For appeal requests for pharmacy medications:

WellCare of South Carolina
Attn: Pharmacy Medication
Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398 
 Fax to: 1-866-201-0657 Fax to: 1-888-865-6531 

We must have your written consent before someone can file an appeal for you. To have someone represent you, you must complete an Appointment of Representative (AOR) form. You and the person you choose to represent you must sign the AOR form. Call us to get this form. Please note - a representative may file for a member who:

  • Has died
  • Is a minor
  • Is an adult and incapacitated (disabled)
  • Has given written permission

(We can help you with your appeal too.)

If the member’s request for appeal is submitted after 60 calendar days from the date on the NABD, then good cause must be shown in order for WellCare to accept the late request. Examples of good cause include, but are not limited to, the following:

  • ­The member did not personally receive the notice of action or received the notice late
  • ­The member was seriously ill, which prevented a timely appeal
  • There was a death or serious illness in the member’s immediate family
  • An accident caused important records to be destroyed
  • Documentation was difficult to locate within the time limits; and/or the member had incorrect or incomplete information concerning the appeals process

We will send you a letter within five business days of getting your appeal. It will let you know we received your appeal. We will review it and send you a decision letter within 30 calendar days from receiving your appeal. You or your authorized representative can review the information we used to make our decision.
An authorized representative is someone you select to act on the behalf of a member to assist them through the appeals process. This person has all beneficiary rights and responsibilities during the appeal process.

Expedited or "Fast" Appeals

There may be times when you or your provider will want us to make a faster appeal decision. This could be because you or your provider thinks that waiting 30 calendar days could seriously harm your health. If so, you can ask for an expedited or “fast” appeal.

You or your provider must call or fax us to ask for a fast appeal. Our fax number is 1-866-201-0657. Written notice is not needed if your expedited appeal request is filed verbally.

We will call you with our decision if we decide you need a fast appeal. We will also send you a letter with our decision within 72 hours from receiving your appeal.

If you ask for a fast appeal and we decide that one is not needed, we will:

  • Change the appeal to the timeframe for a standard decision (30 calendar days)
  • Make reasonable efforts to call you
  • Follow up with a written letter within 2 calendar days
  • Tell you over the phone and in writing that you may file a grievance about the denial of the fast appeal request

Additional Information

You or your authorized representative can give us more information if you think it’ll help your appeal (regular or fast). You may do this in writing or in person. You can do this at any time during your appeal. You will have a limited time to submit additional information for a fast appeal.

You may also ask us for up to 14 more calendar days to give us more information. We may ask for 14 more calendar days to make a decision as well. (This is called an extension.) We will do this if we feel more information is needed and it’s in your best interest. We will first call you to let you know of the extension and then we will send you a letter within 2-days stating that we are extending your appeal and why. You also have the right to file a grievance about the added time to resolve the appeal.

State Fair Hearing

If you don’t agree with our appeal decision - and you've completed the appeal steps with our health plan - or, if our appeal decision was not made within the  required timeframe (30-calendar days for standard appeals or 72 hours for fast appeals), you may request a State Fair Hearing. you have another option. You can ask in writing for a State Fair Hearing (hearing, for short).

Hearings are used when you were denied a service or only part of the service was approvedOnly you or your authorized representative can ask for a State Fair Hearing.

A hearing officer from the State will decide if we made the right decision. You, your friend, a relative, legal counsel or other spokesperson who has your written consent may ask for a State Fair Hearing. This must be done within 120 days from the date of Notice of Appeal Resolution you received from us

If you request a hearing, the request must:

  • Be in writing and specify the reason for the request
  • Include your name, address and phone number
  • Indicate the date of service or the type of service denied
  • Include your provider’s name

A State Fair Hearing is a legal proceeding. Those who attend the hearing include:

  • You
  • Your authorized representative (if you’ve chosen one)
  • A WellCare of Nebraska representative
  • A hearing officer from Medicaid and Long-Term Care (MLTC) 

You can also request to have your hearing over the phone.

At the hearing, we’ll explain why we made our decision. You or your authorized representative will tell the hearing officer why you think we made the wrong decision. The hearing officer will decide whether our decision was right or wrong.

You may request a State Fair Hearing at this address: 

South Carolina Department of Health
and Human Services
Division of Appeals and Hearings
P.O. Box 8206
Columbia, SC 29202-8206

 

Or call 1-800-763-9087.

Continuation of Benefits During the Appeals Process

We will continue covering your medical services during your appeal request and State Fair Hearing if all of the following are meet. To do this:

  • You or your authorized representative with your written consent must file your appeal with us and ask to continue your benefits within 10 calendar days after we mail the Notice of Adverse benefit determination; or
  • Within 10 calendar days of the intended effective date of the plan’s proposed action, whichever is later
  • The appeal or hearing must address the reduction, suspension or stopping of a previously authorized service
  • The services were ordered by an authorized provider
  • The period covered by the original authorization cannot have ended

Be sure to ask us to continue your benefits within the 10 calendar day time frame. If you don’t, we will have to deny your request.

If your services are continued during an appeal or a hearing, you can keep getting them until:

  • You decide to drop the appeal or hearing
  • You do not appeal within 10 calendar days from when the Plan mails an adverse Notice of Action, or you do not request a hearing within 10 calendar days from when the Plan mails an adverse Notice of Appeals Resolution whichever is later.
  • The hearing officer does not decide in your favor

If the hearing is decided in your favor, we’ll approve and pay for the care that is needed. We will do this as quickly as possible as but no longer than 72-hours from the decision.

If the hearing is not decided in your favor, you will have to pay for the cost of the care you got during the hearing process. You may also have to pay for costs that we’ve paid.

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What is a Grievance?

A grievance is when you tell us about a concern you have with our plan. It can also be about a provider and/or a service. These grievances may be about:

  • Quality-of-care issues.
  • Wait times during provider visits.
  • The way your providers or others act or treat you.
  • Unclean provider offices.
  • Not getting the information you need. 

How to File a Grievance

The state of South Carolina allows members to file a grievance at anytime from the event that caused the dissatisfaction. You can file a grievance by calling or writing to us. To do so by phone, call Member Services at 1-888-588-9842 (TTY 1-877-247-6272). To write us, send mail to:

WellCare Health Plans
Attn: Grievance Department
P.O. Box 31384
Tampa, FL 33631-3384

You can fax it too. Our toll-free fax number is 1-877-297-3112.

Who Can File a Grievance?

You can file the grievance yourself. Or you can have someone file it for you. (This includes your PCP or another provider.) We must have your written permission before someone can file a grievance for you. If at any time you need help filing one, call us.

If you wish to use a representative, then he or she must complete an Appointment of Representative (AOR) statement. You and the person you choose to represent you must sign the AOR statement. 

When Will I Receive a Response?

Within five business days of getting your grievance, we will mail you a letter. It will tell you we received your grievance. We will send you another letter with our decision within 90 days or sooner.

We may apply a 14 day extension to your grievance resolution. We will notify you orally and in writing. As a member you may request a 14 day extension of your grievance, you may do so by calling Member Services at 1-888-588-9842 (TTY 1-877-247-6272) or You may send your request for extension in writing to:

WellCare Health Plans
Attn: Grievance Department
P.O. Box 31384
Tampa, FL 33631-3384

You can fax it too. Our toll-free fax number is 1-877-297-3112.

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Second Level Review (Appeal) of the Original Decision

When you receive your notification of WellCare’s grievance resolution, and you are dissatisfied with the resolution regarding adverse decisions that affect your ability to receive benefits, access to care, access to services or payment for care of services, you may request a second level review with WellCare.

The second level review will follow the same process and procedure outlined for the initial review.  You may file your second level grievance review within 30 days of receiving your grievance decision letter. You will receive an acknowledgement letter within 5 business days, and we will send you a resolution within 90 calendar days.  Your second-level review will be performed by person(s) not involved in the first review.

What is a State Fair Hearing?

You can ask for a State Fair Hearing after we make our appeal decision. You must ask within 30 calendar days of getting our decision. 

A provider can act for a member in hearings with the member's written permission in advance. Provider can't require members to appoint them as a condition of getting services. 

To ask for hearing, call 1-800-763-9087 or write to: 

South Carolina Department of Health
and Human Services
Division of Appeals and Hearings
P.O. Box 8206
Columbia, SC 29202-8206

You also can make a request online using SCDHHS’ form at https://msp.scdhhs.gov/appeals/site-page/file-appeal  

Visit https://msp.scdhhs.gov/appeals/ to:

  • Reschedule hearings
  • Cancel hearings
  • Withdraw appeal requests

And remember, for a State Fair Hearing:

  • Ask within 30 calendar days
  • Ask only after our appeal decision
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Last Updated On: 5/18/2021