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Appeals and Grievances

We want you to let us know right away if you have any complaints or concerns with the services or care you receive.

In this section, we'll explain how you can tell us about these concerns.

There are two ways we handle concerns. They are:

State Law Allows You to Voice a Concern You May Have With Us.

The state has also helped to set the rules for how you voice that concern. The rules include what we must do when we get your concern. 

When you share your complaint or concern, keep in mind:

  • We must be fair
  • We cannot disenroll you from our plan
  • We cannot treat you differently because you let us know you didn’t like something

If you have questions, give us a call. Our toll-free number is 1-877-389-9457 (TTY 1-877-247-6272). We're happy to help if you speak a different language or need this information in a different format (like large print or audio).

What is a Grievance?

A grievance is when you let us know that you're not happy with our plan, a provider or a benefit/service. Examples of issues that could lead to a grievance include:

  • Quality of the care you received
  • Wait times during provider visits
  • The way your providers or others behave
  • Not being able to reach someone by phone
  • Not getting information you need
  • An unclean or poorly kept provider’s office

You or someone you allow to speak for you may file a grievance. This could be a friend, a relative or a lawyer. You must tell us in writing that they have your OK to speak for you. A provider may not file a grievance for you, unless he or she is acting as your authorized representative.

You can file a grievance with us over the phone or in writing.

You must file your grievance within 30 calendar days from the day that the issue you are not happy about took place.

NOTE: A nurse or doctor may review your grievance if it's about a medical issue.

Steps in the Grievance Process  

Steps in the Grievance Process

1)  Contact Us 
  • Call 1-877-389-9457 (TTY 711 or 1-877-247-6272) with your concern – we’ll try and fix it over the phone (especially if it’s because we need more information)
  • You can also mail your grievance to us:

WellCare of Kentucky
Attn: Appeals and Grievance Department
P.O. Box 436000
Louisville, KY 40253


 
2)  First notification to you  
  • We’ll send you a letter within 5 business days after getting your grievance to let you know we are looking into your concerns
  • If we’re able to resolve the issue within these 5 days, the letter will have our decision
3) Second notification to you   
  • If we don’t make a decision within the 5 business days, we’ll have a decision for you within 30 calendar days after getting your grievance
  • We will send you a letter within 30 calendar days after getting your grievance with our decision
  • You may ask us for up to 14 more calendar days so you can provide more information
  • We also may ask for 14 more calendar days to make a decision, if we think more information is needed and it’s in your best interest

What is an Appeal?

An appeal is when you don't agree with a decision we made about your care. You can appeal any service, including Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. You can ask for an appeal if:

  • You're not getting the care you feel is covered by our plan
  • We deny or limit a service or prescription you or your provider asks us to provide
  • We reduce, suspend or stop services you’ve been getting that we already approved
  • We do not pay for the health care services you received
  • We fail to give services in the required time-frame
  • We fail to give you a decision in the required time frame on an appeal that you already filed
  • 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 few doctors
  • You don't agree with a denial of financial liability (including cost sharing such as co-payments and premiums)

You'll get a letter from us when any of these actions occur. It’s called a "Notice of Adverse Benefit Determination" (NABD). It’ll tell you how and why we made our decision. You can file an appeal if you do not agree with our decision.

You or your authorized representative can file an appeal. This includes your PCP or another provider. We can also help to file an appeal for you.

We must have your written consent before someone can file an appeal for you. If you wish 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

You must file your appeal request within 60 calendar days of the date on the NABD. You can file by calling or writing to us. 

To write to us, please send your request to:

WellCare of Kentucky
Attn: Appeals and Grievance Department
P.O. Box 436000
Louisville, KY 40253

To file an appeal by phone, call 1-877-389-9457 (TTY 711 or 1-877-247-6272).

IMPORTANT: If you call in your appeal, you must follow up with a written, signed request. Make sure to do this within 10 calendar days of calling in your appeal. (Expedited appeals received over the phone do not require a follow-up written request.)

You must file your appeal request within 60 calendar days. If you don't send us your appeal request within 60 calendar days of the date on the decision notice, your request may be denied.

We'll send you a letter within 5 business days of getting your appeal request. It'll let you know we received your appeal. If we’re able to make a decision within the 5 business days, the letter will have our decision. If we can't make a decision within the 5 business days, we'll let you know our decision within 30 calendar days. We will send you a letter with our decision.

IMPORTANT: If you call in your appeal, you must follow up with a written, signed request. Make sure to do this within 10 calendar days of calling in your appeal. (Expedited appeals received over the phone do not require a follow-up written request.)

You must file your appeal request within 60 calendar days. If you don't send us your appeal request within 60 calendar days of the date on the decision notice, your request may be denied.

We'll send you a letter within 5 business days of getting your appeal request. It'll let you know we received your appeal. If we’re able to make a decision within the 5 business days, the letter will have our decision. If we can't make a decision within the 5 business days, we'll let you know our decision within 30 calendar days. We will send you a letter with our decision.

You, your authorized representative or provider can look over the information used to make your appeal decision. This includes:

  • Your medical records
  • Guidelines we used
  • Our appeal policies and procedures

We'll need your written permission to let others see this information.

Expedited Appeal Requests

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

You or your provider must call or fax us to ask for a Expedited Appeal. Call us at 1-877-389-9457 (TTY 711 or 1-877-247-6272). Or fax it to 1-866-201-0657. If you file your Expedited Appeal by phone, written notice is not needed.

You'll need to ask your provider to say that you need a Expedited Appeal. You will have a limited time to submit the information for a Fast Appeal. If you ask for a Expedited Appeal without your provider’s support, then we'll decide if one is critical for your health.

If we decide you need a Expedited Appeal, we'll call you with our decision. We'll also send you a letter with our decision within 72 hours.

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

  • Change the appeal to the time frame for a standard decision (30 calendar days)
  • Make reasonable efforts to call you
  • Follow up with a written letter within 2 calendar days

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 Expedited 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’ll do this if we feel more information is needed and it's in your best interest. We’ll provide you with written notice of the reason for the delay within 2 business days of deciding to extend the time frame. We’ll also tell you that you have a right to file a grievance if you don’t agree with the plan taking more time.

You also have the right to review your appeal during or after the appeal is complete. 

Here's a re-cap of the time frames we'll use when making appeal decisions:

Type of Appeal Request Maximum Amount of Time We'll Take to Make a Decision
 Type of Appeal Request                              Maximum Amount of Time We'll Take to Make a Decision 
 Expedited Appeal  72 hours or sooner
(if your health requires it)
Pre-service appeal
(for care you have not yet received)
 
30 calendar days  
Post-service appeal
(for care you have no yet received) 
 
30 calendar days 

State Fair Hearing Process

If you don't agree with our appeal decision or we do not resolve your appeal within 30 calendar days, you have another option. You can ask in writing for a State Fair Hearing (“hearing,” for short). Before you can ask for a hearing, you must complete our appeal process. This means you can only ask for a hearing after you've received our final appeal decision letter. You may also ask for a hearing if the appeal decision is made untimely. Hearings are used when you were denied a service or only part of the service was approved.

Only you or your authorized representative can ask for a State Fair Hearing.

A hearing officer from the Kentucky Cabinet for Health and Family Services 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 the final appeal decision letter.

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 Kentucky representative
  • A hearing officer from the Kentucky Cabinet for Health and Family Services

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 if we made the right decision.

You may request a State Fair Hearing at this address:

Department for Medicaid Services
Division of Program Quality and Outcomes
275 East Main Street, 6C-C
Frankfort, KY 40621

Continuation of Benefits During an Appeal or State Fair Hearing

You can ask that we continue to cover your medical services during your appeal request and/or State Fair Hearing. To do this:

  • You or your authorized representative 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 be for the reduction, suspension or stopping of a previously authorized service
  • The service must have been ordered by an authorized provider
  • The time period covered by the original authorization cannot have ended

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

If your benefits are continued during a hearing, you can keep getting them until:

  • You decide to drop the hearing
  • 10 calendar days pass after we mail our appeal decision letter, unless you request a hearing with continuation of benefits within 10 calendar days from the date we mail this letter
  • The hearing officer does not decide in your favor
  • The time period or service limits of a previously authorized service have ended

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, but no later than 72 hours after we receive the notice changing 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.


Appeals Request

 

Complete this form to submit an appeal.

Grievances Request

 

Complete this form to submit a grievance.

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Last Updated On: 11/7/2018