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Sunday, June 6, 2010

Submission of denial claim Grievances

From wellcare insurance

A member or provider acting on behalf the member and with the member’s written consent may file a grievance either verbally or in writing within 60 calendar days after the date of the occurrence that initiated the grievance.  A verbal request may be followed up with a written request, but the time frame for resolution begins the date the plan receives the verbal filing.

If the member wishes to appoint another person as their representative, he/she must complete an Appointment of Representative statement. The member and the person who will be representing the member must sign the
statement. This form is located in the Forms section of this manual.

The Plan will ensure that punitive action is not taken against a provider who files a grievance on a
beneficiary’s behalf or supports a member’s grievance. The Plan will make a determination on a grievance within the following time frames:

 Expedited Request: 24 hours
 Standard Request: 30 calendar days

The Plan gives members reasonable assistance in completing forms and other procedural steps, including
but not limited to providing interpreter services and toll-free numbers with TTY/TDD and interpreter
capability. Members will be provided reasonable opportunity to present evidence and allegations of fact or
law in person as well as in writing.

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