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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: 

  1. Grievances (or complaints)
  2. Appeals

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 1-855-599-3811 (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).

Grievances

A grievance is a complaint about our plan, a provider or a benefit/service. For example, it could be about:

  • 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, legal counsel or their spokesperson. You must tell us in writing that they have your OK to speak for you. You may file a grievance with us over the phone or in writing. A provider may not file a grievance for you, unless he or she is acting as your authorized representative.

You or your authorized representative may file a grievance at any time.

Please note: We may have a nurse or doctor review your grievance if it’s about a medical issue.

Steps in the Grievance Process

1

Contact us

  • Call 1-855-599-3811 (TTY 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 Nebraska
Attn: Grievance Department
P.O. Box 31384
Tampa, FL 33631

2

First notification to you

  • We’ll send you a letter within 10 calendar days after getting your grievance to let you know we got it, and that we are looking into your concerns.
  • If we’re able to resolve the issue within these 10 calendar days, the letter will let you know of our decision.

3

Second notification to you

  • If we don’t make a decision within the 10 calendar days, we’ll have a decision for you within 90 calendar days after getting your grievance.
  • We will send you a letter within 90 calendar days after getting your grievance with our decision.

 

Appeals

An appeal is a complaint about a decision we made about approving or paying for your care. You can appeal any service. 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 were 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 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
  • We believe you should have financial liability but you don't agree

When we make such decisions, you’ll get a letter from us. It’s called a “Notice of Adverse Benefit Determination.”or “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 must file your appeal request within 60 calendar days of the date on the notice letter. You can file by calling or writing to us. To do so by phone, call 1-855-599-3811 (TTY 1-877-247-6272). 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.) Requests for fast appeals made over the phone do not require a follow-up written, signed request.

Appeal Request FormThis PDF document will open in a new window.

Send Your Written Appeal Requests Here

For appeal requests for medical services:

WellCare of Nebraska
Attn: Appeals Department
Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368

For appeal requests for pharmacy medications:

WellCare of Nebraska
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

You or your authorized representative can file the appeal. (This includes your PCP or another provider.)

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

Your appeal request must be filed with us within 60 calendar days. If you don’t send us your appeal request within 60 calendar days of the date on the Notice of Adverse Benefit Determination, your request may be denied.

Within 10 calendar days of getting your appeal request, we’ll send you a letter to tell you we’ve received it. Sometimes we can make a decision within the 10 calendar days and we’ll send you a final decision letter. If not, we’ll let you know our decision within 30 calendar days after we get your written appeal or your oral appeal with your written confirmation.

Fast 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 fast appeal.

You or your provider must call or fax us to ask for a fast appeal. Call us at 1-855-599-3811 (TTY 1-877-247-6272). If your fast appeal is filed by phone, written notice is not needed.

You can ask your provider to help you file a fast appeal. For a fast appeal, there is a limited amount of time that you or your provider has to send the information. If you ask for a fast appeal without your provider’s support, then we’ll decide if one is critical for your health.

If we decide you need a fast appeal, we’ll call you with our decision within 72 hours. We’ll also send you a follow-up letter with our decision.

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

  • Handle the appeal in the standard time frame and make a standard decision within 30 calendar days
  • Make reasonable efforts to call you, to tell you we are working the file as a standard appeal; and
  • Follow up with a written letter within 2 calendar days

You will not be treated differently or punished for filing a grievance or appeal. This is also true for a provider who supports a member’s grievance or appeal.

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

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

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

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.

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

Fast appeal

72 hours or sooner

(if your health requires it)

Standard appeal (pre-service and post-service)

30 calendar days

State Fair Hearing Process

If you don’t agree with our appeal decision - and you've completed the internal appeal steps - 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 approved. Only 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 or, if the appeal decision was not made within the appeal timeframe, you may request a State Fair Hearing.

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:

Legal Services - Hearing Section
P.O. Box 98914
Lincoln, Nebraska 68509-8914

Continuation of Benefits During an Appeal or State Fair Hearing

You may ask us to continue covering your medical services during your appeal request and/or State Fair Hearing if all of the below is met. 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
  • 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
  • The member requests an extension of benefits

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
  • The hearing officer does not decide in your favor
  • The time 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 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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Last Updated On: 7/10/2018