The State of Wisconsin defines a grievance… “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:
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 by a company that is not affiliated with Quartz.
Maximus Federal Services handles the external review process and requires you to fill out the Review Request Form. In most cases, you must complete any mandatory appeals or opportunities for reconsideration offered by your health plan or insurance issuer before Maximus will do an external review. In urgent situations, Maximus may be able to do a review even if you have not made all appeals and reconsiderations. Maximus must receive the completed form within four months of the date your insurer sent you a final decision denying your services or your claim for payment.