Individual & Family Plan: Wisconsin Member 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.

• Appointment of Authorized Representative Form
• Appeal Filing Form
• Formulary Exception Form

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]