Appeals and Grievances

Important information about your appeals rights

There are two kinds of appeals:

1. Standard appeal: You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal for items and services 30 calendar days after we get your appeal or 7 calendar days after we receive your Part B drug appeal. For Part B or Part D prescription drugs you will get a written answer within 7 calendar days after we get your appeal. Our decision for items and services might take longer if you ask for an extension or if we need more information about your case. We will tell you if we’re taking extra time and will explain why more time is needed. We cannot take an extension for Part B drug appeal decisions. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.
   
2. Fast appeal: For items, services and Part B drugs, you will get an answer within 72 hours after we get your fast appeal, or 7 calendar days for a Part B or Part D prescription drug. If you ask for more time, or we need to gather more information, we can take up to 14 more calendar days. We can’t take extra time to make a decision if your appeal is for a Part B or Part D prescription drug. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you an answer within 30 calendar days for items and services and within 7 calendar days for Part B drugs.

How to ask for an appeal with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan):

Step 1:  Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a authorized representative including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf.  Your written request must include:

• Your name;
• Your address;
• Your Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.
• Please include copies of any additional information that may be important to your Appeal, and mail/fax that information to the following address/fax number below. The timeframe to submit additional information for an expedited appeal is limited due to the short timeframe to process your appeal:

You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision, at no cost to you.

Step 2: Mail, fax, hand-deliver your appeal or call us.

For a Standard or Fast Appeals:

• Member Appeal Form Part C (PDF)
• Part D Appeal (Redetermination) Form

Medical (Part C) Appeals for Items, Services and Part B Drugs:

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105
Phone: 1-855-735-4398 (TTY:711) 
Fax: 1-844-273-2671

Prescription Drug Appeals (Part D)

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Medicare Part D Appeals
P.O. Box 31383
Tampa, FL  33631-3383
Fax: 1-866-388-1766

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

What happens next?  

If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.

You may also have the right to request a State Fair Hearing:

You have the right to ask for a State Fair Hearing if we denied your South Carolina Healthy Connections Medicaid service. You may name someone to represent you. A doctor or other medical provider may also represent you. You or your representative must ask for the State Fair Hearing within 120 calendar days of the date on the Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) letter with the decision. If you do not ask for a State Fair Hearing within 120 calendar days, you may lose your right to a fair hearing.

You have the right to ask for a State Fair Hearing with the South Carolina Department of Health and Human Services (SCDHHS), Division of Appeals and Hearings. Anytime you receive a notice of denial about a Healthy Connections Medicaid service, the letter will tell you how you can file an appeal with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) or ask for a State Fair Hearing with SCDHHS. Fill out the State Fair Hearing form and mail it to SCDHHS - Division of Appeals and Hearings. You can also fax your request to 1-803-255-8206. You can request a hearing within 120 calendar days of the date on the initial denial letter/state hearing rights notice.

If you are asking for a State Fair Hearing because the plan decided to reduce or stop a service you are already getting, you can ask that your benefits for that service continue during the Level 2 Appeal with the Division or Appeals and Hearings. You must make the request on or before the later of the following in order to continue your benefits:

• Within 10 calendar days of the plan’s Level 1 Appeal decision; or 
• The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service while your appeal is processing.

If the decision of the independent reviewer is not completely in your favor, you may request a State Fair Hearing in addition to any other appeal rights.

Step 1: You or your authorized representative must ask for a State Fair Hearing (in writing) within 120 calendar days of the date of the notice of denial. If you want your provider to request the State Fair Hearing for you, you must give written permission (complete an Authorized Representative Form) for the doctor to do so.

Your written request must include:

• Your name;
• Your address;
• Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

Step 2: If you want to ask for a State Fair Hearing related to a standard Healthy Connections Medicaid item or service:

Send your request to:

Mail:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings (Suite 901)
P.O. Box 8206
Columbia, SC 29202-8206
Phone: 1-803-898-2600 (TTY: 711)
Fax: 1-803-255-8206

How to get a total number of grievances, appeals and exceptions filed with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)

To obtain a total number of grievances, appeals, and exceptions, please call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

What is a grievance?

A grievance is a complaint about anything other than benefits, coverage or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times or the customer service you receive. You would also file a grievance if you did not think we responded quickly enough to your request for coverage determination or organization determination or to your appeal. Grievances are responded to within 30 calendar days.

Filing a grievance

You or your authorized representative can file a grievance by:

• Calling Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday.  After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

OR

• Completing a Complaint Form (PDF) or writing us a letter. Include your name, Wellcare Prime ID number, address and telephone number and the reason why you are not happy, and mail it to:
  
  Mail:
  Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
  Attn: Appeals and Grievances
  7700 Forsyth Blvd.
  St. Louis, MO 63105
  Phone: 1-855-735-4398 (TTY:711)
  Fax: 1-844-273-2671

OR

• Calling Medicare (1-800-633-4227) (TTY: 1-877-486-2048). Calls to this number are free, 24 hours a day, seven days a week.

OR

• Visiting Medicare’s website.

Important information about your appeals rights

There are two kinds of appeals:

1. Standard appeal: You have the right to appeal if you don’t agree with a decision we make about services or payment. We will review our decision and let you know what we decide. You will get a written answer on a standard appeal for items and services 30 calendar days after we get your appeal or 7 calendar days after we receive your Part B drug appeal. For Part B or Part D prescription drugs you will get a written answer within 7 calendar days after we get your appeal. Our decision for items and services might take longer if you ask for an extension or if we need more information about your case. We will tell you if we’re taking extra time and will explain why more time is needed. We cannot take an extension for Part B drug appeal decisions. If your appeal is for payment of a service you have already received, we will give you a written answer within 60 calendar days.
   
2. Fast appeal: For items, services and Part B drugs, you will get an answer within 72 hours after we get your fast appeal, or 7 calendar days for a Part B or Part D prescription drug. If you ask for more time, or we need to gather more information, we can take up to 14 more calendar days. We can’t take extra time to make a decision if your appeal is for a Part B or Part D prescription drug. You can ask for a fast appeal if you or your doctor believe your health could be harmed by waiting up to 30 calendar days for a decision.

We will give you a fast appeal if a doctor asks for one for you or supports your request. If you ask for a fast appeal without support from a doctor, we will decide if your request requires a fast appeal. If we don’t give you a fast appeal, we’ll give you an answer within 30 calendar days for items and services and within 7 calendar days for Part B drugs.

How to ask for an appeal with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan):

Step 1: You, your authorized representative or your doctor must ask us for an appeal.  Your written request must include:

• Your name;
• Your address;
• Your Wellcare by Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

You can ask to see the medical records and other documents we used to make our decision before or during the appeal and a copy of the guidelines we used to make our decision, at no cost to you.

Step 2: Mail, fax your appeal or call us.

For a Standard or Fast Appeals:

• Member Appeal Form Part C (PDF)
• Part D Appeal (Redetermination) Form

Medical (Part C) Appeals for Items, Services and Part B Drugs:

Mail:
Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Appeals and Grievances
Medicare Operations
7700 Forsyth Blvd.
St. Louis, MO 63105
Phone: 1-855-735-4398 (TTY:711)
Fax: 1-844-273-2671

Prescription Drug Appeals (Part D)

Mail:

Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
Medicare Part D Appeals
P.O. Box 31383
Tampa, FL  33631-3383
Fax: 1-866-388-1766

Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

What happens next?  

If you ask for an appeal and we continue to deny your request for a service or payment of a Medicare-covered service, we will send you a written decision and forward your case to the Medicare Independent Review Entity (IRE). If the IRE denies your request, the written decision will explain if you have additional appeal rights.

You may also have the right to request a State Fair Hearing:

You have the right to ask for a State Fair Hearing if we denied your South Carolina Healthy Connections Medicaid service. You may name someone to represent you. A doctor or other medical provider may also represent you. You or your representative must ask for the State Fair Hearing within 120 days of the date on the Wellcare by Prime Absolute Total Care (Medicare-Medicaid Plan) letter with the decision. If you do not ask for a State Fair Hearing within 120 days, you may lose your right to a fair hearing.

You have the right to ask for a State Fair Hearing with the South Carolina Department of Health and Human Services (SCDHHS), Division of Appeals and Hearings. Anytime you receive a notice of denial about a Healthy Connections Medicaid service, the letter will tell you how you can file an appeal with Wellcare by Prime Absolute Total Care (Medicare-Medicaid Plan) or ask for a State Fair Hearing with SCDHHS. Fill out the State Fair Hearing form and mail it to SCDHHS - Division of Appeals and Hearings. You can also fax your request to 1-803-255-8206. You can request a hearing within 120 calendar days of the date on the initial denial letter/state hearing rights notice.

If you are asking for a State Fair Hearing because the plan decided to reduce or stop a service you are already getting, you can ask that your benefits for that service continue during the Level 2 Appeal with the Division or Appeals and Hearings. You must make the request on or before the later of the following in order to continue your benefits:

• Within 10 calendar days of the plan’s Level 1 Appeal decision; or 
• The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service while your appeal is processing.

If the decision of the independent reviewer is not completely in your favor, you may request a State Fair Hearing in addition to any other appeal rights.

Step 1: You or your authorized representative must ask for a State Fair Hearing (in writing) within 120 days of the date of the notice of denial. If you want your provider to request the State Fair Hearing for you, you must give written permission (complete an Authorized Representative Form) for the doctor to do so.

Your written request must include:

• Your name;
• Your address;
• Wellcare Prime ID number;
• Your reasons for appealing; and
• Your medical records, doctor’s letter or other information that proves why you need the item or service. Call your doctor if you need this information.

Step 2: If you want to ask for a State Fair Hearing related to a standard Healthy Connections Medicaid item or service:

Send your request to:

Mail:
South Carolina Department of Health and Human Services
Division of Appeals and Hearings (Suite 901)
P.O. Box 8206
Columbia, SC 29202-8206
Phone: 1-803-898-2600 (TTY: 711)
Fax: 1-803-255-8206

How to get a total number of grievances, appeals and exceptions filed with Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)

To obtain a total number of grievances, appeals, and exceptions, please call Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

What is a grievance?

A grievance is a complaint about anything other than benefits, coverage or payment. You would file a grievance if you had any type of problem with the quality of your medical care, waiting times or the customer service you receive. You would also file a grievance if you did not think we responded quickly enough to your request for coverage determination or organization determination or to your appeal. Grievances are responded to within 30 calendar days.

Filing a grievance

You or your authorized representative can file a grievance by:

• Calling Member Services at 1-855-735-4398 (TTY:711). Hours are from 8 a.m. to 8 p.m., Monday through Friday.  After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

OR

• Completing a Complaint Form (PDF) or writing us a letter. Include your name, Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan) ID number, address and telephone number and the reason why you are not happy, and mail it to:
  
  Mail:
  Wellcare Prime by Absolute Total Care (Medicare-Medicaid Plan)
  Attn: Appeals and Grievances
  7700 Forsyth Blvd.
  St. Louis, MO 63105
  Phone: 1-855-735-4398 (TTY:711)
  Fax: 1-844-273-2671

OR

• Calling Medicare (1-800-633-4227) (TTY: 1-877-486-2048). Calls to this number are free, 24 hours a day, seven days a week.

OR

• Visiting Medicare’s website.