Individual & Family Plan Members
Appeals & Grievances
Individual & Family member appeals
Sometimes our Customer Service staff cannot clear up the matter. In that case, our Appeals Specialists will help you with the appeal process. Please check your Certificate of Coverage or Summary Plan Document for a full description of your appeal rights.
Illinois Appeals
Quartz’s mission is to investigate all grievances and appeals appropriately and work to resolve them within the required time period. The State of Illinois defines an appeal as a decision or action by a health care plan that relates to:
- Health care services including but not limited to procedures or treatments for an enrollee with an ongoing course of treatment ordered by a health care provider, the denial of which could significantly increase the risk to an enrollee’s health, or;
- A treatment referral, service, procedure, or other health care service, the denial of which could significantly increase the risk to an enrollee’s health
Appeals can be filed orally or in writing. Quartz will review if the situation is urgent or will be handled as a standard appeal.
Minnesota Appeals
Quartz’s mission is to investigate all grievances and appeals appropriately and work to resolve them within the required time period. The State of Minnesota’s definition of “Appeal” means a formal request, either orally or in writing, to reconsider a determination not to certify an admission, extension of stay, or other health care service.
There is a 180-day time limit for filing a pre-service appeal. Expedited appeals will be resolved in 72 hours and standard appeals will be resolved in 30 days. You or your provider can file an appeal.
Your provider will need your approval which can be submitted on the Appointment of Authorized Representative Form.
In some cases, the State of Minnesota gives members the ability to file an external independent review upon completion of the internal appeal process. You may obtain the Request for External Appeal form by phone, email, or by submitting a written request.
Mail:
Minnesota Department of Health
Managed Care Systems Section
P.O. Box 64882
St. Paul, MN 55164-0882Phone:
(651) 201-5100 or (800) 657-3916Email:
[email protected].
Wisconsin Appeals
Quartz’s mission is to investigate all grievances and appeals appropriately and work to resolve them within the required time period. There is no time limit for filing appeals or grievances. Expedited appeals will be resolved in 72 hours and standard appeals will be resolved in 30 days.
The State of Wisconsin defines a grievance as follows: “Grievance” means any dissatisfaction with an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured including any of the following:
- Provision of services.
- Determination to reform or rescind a policy.
- Determination of a diagnosis or level of service required for evidence−based treatment of autism spectrum disorders.
- Claims practices.
You or your provider can file an appeal in writing. Your provider will need your approval which can be submitted on the Appointment of Authorized Representative form. Once an appeal begins, you will be contacted by an Appeals Specialist and an invitation will be mailed to attend a Reconsideration Meeting. At this meeting, you will be able to make a statement about why you feel the appeal should be approved.
The State of Wisconsin gives members the ability to file an external review once the appeal process has been exhausted. You or your authorized representative may do so by submitting a request for an external review in writing to Quartz within four (4) months of your appeal decision letter. You may also begin an external review at the same time as the internal appeals process if it is an urgent situation or you are in an ongoing course of treatment.
To file an external review, send your request to:
Quartz
Attn.: Appeals Specialists
2650 Novation Parkway
Fitchburg, WI 53713
Fax: (608) 644-3500
Email: [email protected]
Contact us
We’re here to help you find the right plan option that works for you and your family. Please call Quartz Customer Success at (800) 362-3310, or if you have worked with an agent in the past, reach out to them with any questions on your Quartz plan options.