There are some treatments and services that you need to get approval for before you get them, or you must get approval to keep getting them. When you ask us to OK a treatment or service, it is called a service authorization request. You can learn more about this in your member handbook.
Sometimes we turn down a service authorization request, or we approve it for an amount that is less than requested. These decisions are called adverse benefit determinations.
If you are not satisfied with our decision about your care:
- You Can File a Plan Appeal
- You can ask for a Plan Appeal, or have someone else ask for you, like a family member, friend, doctor, or lawyer. If you told us before that someone may represent you, that person may ask for the Plan Appeal. If you want someone new to act for you, you and that person must sign and date a statement saying this is what you want. Or, you can both sign and date the attached Plan Appeal Request Form that is attached to the Initial Benefit Determination notice.
- You have 60 calendar days from the date of the Initial Benefit Determination notice to file an appeal.
- You can call Customer Service at 1-877-395-4282 (TTY 711) for help filing a Plan Appeal.
- We will not treat you any differently or act badly toward you because you file a Plan Appeal.
- If you ask for a Plan Appeal by phone, unless it is fast tracked, you must also send your Plan Appeal to us in writing to:
WellCare Appeals Department
P.O Box 31368
Tampa, FL 33631-3368
If you are receiving services and we decided to reduce, suspend or terminate your current services and you want to keep your services the same then,
- You must ask for a Plan Appeal within 10 calendar days of the date of the Initial Benefit Determination notice or by the date the decision takes effect, whichever is later.
- Your services will stay the same until we make our decision. If the Plan Appeal is not decided in your favor, you may have to pay for the services you got while waiting for the decision.
Your Action Appeal Will Be Reviewed Under the Fast-Track Process If:
- You or your doctor asks to have your appeal reviewed under the fast-track process. Your doctor would have to tell us how a delay will harm your health. If your request for fast track is denied we will tell you. Then your appeal will be reviewed under the standard process; or
- Your request was denied when you asked to keep getting care that you are now getting or need to extend a service that has been provided.
- Fast-track appeals can be made by phone. They do not have to be followed up in writing.
What Happens After We Get Your Appeal?
- We will tell you we received your Plan Appeal and begin our review. We will let you know if we need any other information from you. If you asked to give us information in person, WellCare will contact you (and your representative, if any).
- We will send you a free copy of the medical records and any other information we will use to make the appeal decision. If your Plan Appeal is fast tracked, there may be a short time to review this information.
- We will send you our decision in writing in 30 days. If fast tracked it will be in 72 hours and we will also contact you by phone. If you win your Plan Appeal, your service will be covered. If you lose your Plan Appeal, we will send you our Final Adverse Determination. The Final Adverse Determination notice will explain the reasons for our decision and any further appeal rights.
- You or someone you trust can file a complaint without he New York state Department of Health at 1-866-712-7197.
2. You can ask for a Fair Hearing.
- You can ask for a Fair Hearing only after you asked for a Plan Appeal and you receive a Final Adverse Determination notice.
- You can also ask for a Fair Hearing only after you have asked for a Plan Appeal and we have not responded to your request or the time for us to decide on your Plan Appeal has expired, including any extensions.
- You will have 120 days from the date of the Final Adverse Determination notice to ask for a Fair Hearing.
- To request a Fair Hearing call 1-800-342-3334 or fill out the form online at http://otda.ny.gov/oah/FHReq.asp
If in any instance you need assistance, please call Customer Service at 1-877-395-4282 (TTY 711).