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Appeals and Grievances

Appeals

WellCare of North Carolina may decide to deny or limit a request your provider makes for you for benefits or services offered by our plan. This decision is called an adverse benefit determination. You will receive a letter from WellCare of North Carolina. This letter will notify you of any adverse benefit determination. Medicaid members have a right to appeal adverse benefit determinations to WellCare of North Carolina. You have 60 days from the date on your letter to ask for an appeal. A member may not agree with our decision on an appeal. If they do not agree, they can ask the NC Office of Administrative Hearings for a State Fair Hearing.

When you ask for an appeal, WellCare of North Carolina has 30 days to give you an answer. You can ask questions and give any updates (including new medical documents from your providers) that you think will help us approve your request. You may do so in four ways:

  • in person
  • in writing
  • by phone
  • online

You can ask for an appeal yourself. You may also ask a friend, a family member, your provider or a lawyer to help you. You can call WellCare of North Carolina at 1-866-799-5318. Or visit our website at www.wellcarenc.com if you need help with your appeal request. It’s easy to ask for an appeal by using one of the options below:

  • MAIL: Fill out and sign the Appeal Request Form in the notice you receive about our decision. Mail it to the address listed on the form. We must receive your form no later than 60 days after the date on the notice.
  • FAX: Fill out, sign and fax the Appeal Request Form in the notice you receive about our decision. You will find the fax number listed on the form. We must receive your form no later than 60 days after the date on the notice.
  • BY PHONE: Call 1-866-799-5318 and ask for an appeal.
  • ONLINE: Pharmacy appeals can be submitted online via our website.
  • Sumibt an online request for drug coverage
  • Submit an online request to review a drug coverage denial

When you appeal, you and any person you have chosen to help you can see the health records and criteria WellCare of North Carolina used to make the decision. If you choose to have someone help you, you must give them written permission.

You can request a copy of your appeal file at any time during the appeals process free of charge. You may also submit additional comments, documents and/or information regarding your appeal. The timeframe to submit additional information is limited for expedited appeals.

Expedited (faster) Appeals

You or your provider can ask for a faster review of your appeal when a delay will cause serious harm to your health. This faster review is called an expedited appeal.

Your provider can ask for an expedited appeal by calling us at 1-866-799-5318. You can ask for an expedited appeal by phone, by mail, or by fax. There are instructions on your Appeal Request Form that will tell you how to ask for an expedited appeal.

Provider Requests for Expedited Appeals

Your provider may ask for an expedited appeal. We will give a decision no later than 72 hours after we get the request. We will call you and your provider as soon as there is a decision. We will send you and your provider a written notice of our decision within 72 hours from the day we received the expedited appeal request.

Member Requests for Expedited Appeals

WellCare of North Carolina will review all member requests for expedited appeals. If your request for an expedited appeal is denied, we will call you during our business hours promptly following our decision. We also will tell you and the provider in writing if your request for an expedited appeal is denied. We will tell you the reason for the decision. WellCare of North Carolina will mail you a written notice within two calendar days.

You may not agree with our decision to deny an expedited appeal request. In this case, you may file a grievance with us (see page 52 for more information on grievances). The appeal will be decided within 30 days of your request. In all cases, we will review appeals as fast as a member’s medical condition requires.

Timelines for Standard Appeals

If we have all the information we need, we will make a decision on your appeal within 30 days from the day the we get your appeal request. We will mail you a letter to tell you about our decision. If we need more information to decide about your appeal, we will:

  • Write to you and tell you what information is needed
  • Explain why the delay is in your best interest
  • Decide no later than 14 days from the day we asked for more information

If you need more time to gather records and updates from your provider, just ask. You or a helper you name may ask us to delay your case until you are ready. Ask for an extension by calling Member Services at 1-866-799-5318 or writing to:

WellCare of North Carolina
Attn: Appeals
PO Box 31368
Tampa, FL 33631-3368

OR

WellCare of North Carolina
Attn: Pharmacy Appeals
PO Box 31398
Tampa, FL 33631-3398

Decisions on Appeals

When we decide your appeal, we will send you a letter. This letter is called a Notice of Decision. If you do not agree with our decision, you can ask for a State Fair Hearing. You can ask for a State Fair Hearing within 120 days from the date on the Notice of Decision.

State Fair Hearings

If you do not agree with WellCare of North Carolina’s decision on your appeal, you can ask for a State Fair Hearing. In North Carolina, State Fair Hearings include an offer of a voluntary mediation session at no cost. This meeting is held before your State Fair Hearing date.

Free and Voluntary Mediations

When you ask for a State Fair Hearing, you will get a phone call from The Mediation Network of North Carolina. The Mediation Network will call you within 5 business days after you request a State Fair Hearing. During this call you will be offered a mediation meeting. The state offers this meeting at no cost to help quickly resolve your disagreement. These meetings are held by phone.

You do not have to accept this meeting. You can ask to schedule just your State Fair Hearing. When you do accept, a Mediation Network counselor will lead your meeting. This person does not take sides. A member of WellCare of North Carolina’s review team will also attend. If the meeting does not help with your disagreement, you will have a State Fair Hearing.

State Fair Hearings

State Fair Hearings are held by the NC Office of Administrative Hearings (OAH). An administrative law judge will review your request. They will also review any new information you may have. The judge will make a decision on your service request. You can give any updates and facts you need to at this hearing. A member of WellCare of North Carolina’s review team will attend. You may ask questions about WellCare of North Carolina’s decision. The judge in your State Fair Hearing is not a part of WellCare of North Carolina in any way.

It is easy to ask for a State Fair Hearing. Use one of the options below:

  • MAIL: Fill out and sign the State Fair Hearing Request Form that comes with your notice. Mail it to the addresses listed on the form.
  • FAX: Fill out, sign and fax the State Fair Hearing Request Form that comes with your notice. You will find the fax numbers you need listed on the form.
  • BY PHONE: Call the Office of Administrative Hearings (OAH) at 1-984-236-1860 and ask for a State Fair Hearing. You will get help with your request during this call.

If you are unhappy with your State Fair Hearing decision, you can appeal to the North Carolina Superior Court in the county where you live. You have 30 days from the day you get your decision from your State Fair Hearing to appeal to the Superior Court. You can also contact the Managed Care Ombudsman Program to get more information about your options. See page 66 for more information about the Ombudsman Program.

State Fair Hearings and Disenrollment Decisions

If you disagree about a decision to change your health plan, you can ask for a State Fair Hearing. This type of State Fair Hearing is different from one about a denied service request. For more information about requesting a State Fair Hearing for disenrollment decisions, see the Member Handbook.

Continuation of Benefits during an Appeal

Sometimes WellCare of North Carolina’s decision reduces or stops a health care service you are already getting. You can ask to continue this service without changes until your appeal is finished. Someone helping you with your appeal can also make that request. Your provider cannot ask for your services to continue during an appeal.

The rules in the section are the same for Appeals and State Fair Hearings.

There are special rules about continuing your service during your appeal. Please read this section carefully!

You will get a notice if WellCare of North Carolina is going to reduce or stop a service you are receiving. You have 10 days from the date we send the letter to ask for your services to continue. The notice will tell you the exact date. The notice will also tell you how to ask for your services to continue while you appeal.

If you ask, WellCare of North Carolina will continue your services from the day you ask until the day get your appeal decision. You or your authorized representative may contact Member Services at 1-866-799-5318. Or contact the Appeals Coordinator on your adverse benefit determination letter. He or she can ask for your service to continue until you get a decision on your appeal.

Your appeal might not change the decision the health plan made about your services. When this happens, Medicaid allows WellCare of North Carolina to bill you for services we paid for during your appeal.

We must get approval from NC Medicaid before we can bill you for services we paid for during your appeal.

Appeals during Your Transition Out of WellCare of North Carolina

You may decide to leave WellCare of North Carolina. This transition may affect your appeal. Please see below for additional information on how we will process appeals at transition. If you will be transitioning out of our plan soon and have an appeal with us, please contact Member Services at 1-866-799-5318 for additional information.

If you lose eligibility during an appeal, the Plan will continue your appeal review if the request is for service(s) you have already received. If the request is for service(s) you have not yet received, the request will be closed as "No longer enrolled with the Plan." If you are currently in the hospital and receiving treatment, the Plan will complete your appeal review.


Grievances

If You Have Problems with Your Health Plan You Can File a Grievance

We hope our health plan serves you well. Do you have a complaint? Talk with your primary care provider. Or call Member Services at 1-866-799-5318 or write to:

WellCare of North Carolina
Attn: Grievance Department
PO Box 31384
Tampa, FL 33631-3384

A grievance and a complaint are the same thing. Contacting us with a grievance means that you are you are unhappy with your health plan, provider or your health services. Most problems like this can be solved right away. Whether we solve your problem right away or need to do some work, we will record your call, your problem and our solution. We will inform you that we have received your grievance in writing. We will also send you a written notice when we have finished working on your grievance.

You can ask a family member, a friend, your provider or a legal representative to help you with your complaint. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filing out any forms, we can help you:

You can contact us by phone or in writing

  • By phone, call Member Services at 1-866-799-5318, 24 hours a day, 7 days a week
    • After business hours, you may leave a message, and we will contact you during the next business day
  • You can write us with your complaint to:


WellCare of North Carolina
Attn: Grievance Department
PO Box 31384
Tampa, FL 33631-3384

If we are not able to resolve your complaint within the same day, we will enter your complaint as a formal grievance. You or your authorized representative may file a complaint or grievance at any time.

Resolving Your Grievance

We will let you know in writing that we got your grievance within 5 days of receiving it.

  • We will review your complaint and tell you how we resolved it in writing within 30 days of receiving your complaint
  • We will acknowledge your grievance within 24 hours of receipt if it is related to the denial of an expedited/fast appeal request
  • If your grievance is about your request for an expedited (faster) appeal, we will tell you how we resolved it in writing within 5 days of getting your complaint
  • If the Plan or your provider needs more information, we may ask for up to 14 more days to make a decision
    • We will call to let you know if we need an extension
  • We will also send you a letter within two (2) days with the reason for the delay
  • You may also ask for an extension, which we will give you at your request
  • You or your authorized representative may file a complaint with the department/state if you are not happy with how we handle your grievance