Contact

At times you may have questions and concerns about benefits, claims or services you receive from WellFirst Health. Sharing your concerns will help us to identify our strengths and weaknesses.

When a question or concern arises, we encourage you to reach out to our Customer Care Center at 866-514-4194. Our Customer Care Specialists will make every effort to resolve your concern promptly and completely. Your input matters, and we encourage you to call with any concerns you may have regarding your health care.

Grievance and appeals procedure

A. Complaint

A complaint is any expression of dissatisfaction expressed to us by the member, or a member's authorized representative, about us or our providers with whom we have a direct or indirect contract. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner.

lf you have a complaint, please contact our Customer Care Center at 866-514-4194. We will document and investigate your complaint and notify you of the outcome. lf your complaint is not resolved to your satisfaction you, your health care provider, or your authorized representative may file a grievance.

B. Grievance

A written complaint submitted by or on behalf of a member expressing dissatisfaction with us, including:

  1. the way we provide services or process claims,
  2. a decision to change or rescind a policy.
  3. an adverse determination made by utilization management
  4. reimbursement for health care services
  5. availability, delivery, or quality of health care services

Under Missouri law, an adverse determination is a denial, reduction, or termination of benefits because the care does not meet our definition of medical necessity, appropriateness, health care setting, level of care or effectiveness.

This grievance process does not apply when a member is requesting coverage of a drug or item not listed on our formulary. These requests are subject to the non-formulary exception process described later in this section.

To file a grievance, you or your authorized representative must send your grievance, to us in writing at the following address:

WellFirst Health
Attention:  Grievance and Appeal Department
P.O. Box 56099
Madison, WI  53705

We will not charge you for filing a grievance with us. When we receive your grievance, our Grievance and Appeal Department will send you an acknowledgement letter within 10 business days. Our acknowledgment letter will advise you of:

  • Your right to submit written comments, documents or other information regarding your grievance;
  • Your right to be assisted or represented by another person of your choosing;
  • Your right to appear before the Grievance and Appeal Committee; and
  • The date and time of the next scheduled Grievance and Appeal Committee meeting.

If you choose to meet with the Grievance and Appeal Committee you may do so either in person or over the phone via teleconference. As described in the acknowledgement letter you must call and schedule a meeting time.

The Grievance and Appeal Committee will consist of:

  • Individuals who were not involved in the initial decision review
  • Other enrollees
  • In cases of an adverse determination, involving medical judgment, a majority of persons that are health care professional of a same and similar specialty.

We will complete our review within 20 business days after receipt of your grievance. If we are unable to complete the research of your grievance in this timeframe, We will notify you in writing on or before the 20th business day, and the review will be completed within an additional 30 business days. The notice will include specific reasons why additional time is needed.

We will automatically send you the following information:

  1. Any new or additional evidence we consider, rely upon, or generate in the course of considering your grievance; or
  2. Any new or additional rationale we use to make our decision.

Within five business days of the completion of the review, We will make a decision on the appropriate resolution, and notify you in writing of the decision. If someone other than you filed a grievance on your behalf, we will notify them in writing within 15 business days after the completion of our review.

If we deny your grievance we will notify you of your right to submit the grievance to the director of the Missouri Department of Insurance (MDI) for review. Your decision to file a grievance with the MDI will not impact your coverage or benefits with Us.

You may file a grievance with the MDI at any time in the following ways:

  • Submit your complaint form electronically
  • Fax to 573-526-4898; or
  • Mail to P.O. Box 690, Jefferson City, MO 65102-0690.

Following the completion of MDI’s review, the director may refer your unresolved medical necessity grievance to the Independent Review Organization (IRO). Within 20 calendar days after receiving your grievance, the IRO will complete a review and submit its opinion to the MDI. Within 25 calendar days of receipt of the opinion, the MDI will notify you of the decision, and it will be binding on you and us.

At any time if you wish to receive a free copy of any other documents relevant to the outcome of your grievance, send a written request to the address listed above.

Expedited Grievance

lf we decide your grievance is urgent according to our criteria, we will resolve your grievance within 72 hours of the time we receive it. Our criteria are based on the expedited grievance provisions of applicable law.

We will automatically treat your grievance as expedited if:

  1. Your concerns are related to a facility admission or concurrent review of a continued facility stay;
  2. Our medical director decides your life, health, or ability to regain maximum function could be jeopardized by the standard review timeframe;
  3. Your health care provider notifies us that you would be subject to severe pain that cannot be adequately managed without the services you requested; or
  4. Your health care provider notifies us that he or she has decided you need care urgently.

You, your authorized representative or your health care provider may request an expedited grievance either orally at 608-828-1991, by fax at 608-252-0812 or in writing at the address listed above. You can make this request in your initial grievance or in a separate communication.

lf you are eligible for an expedited internal grievance and also for external review, you can request that your internal and external reviews happen at the same time.

Non-Formulary Exception

If you or your prescribing health care provider wish to grieve a denied non-formulary exception to coverage request you may do so in writing at the address listed above or orally at the phone number listed above.

Standard Non-Formulary Exception
If your request is not urgent we will follow our standard non-formulary exception grievance timeline.

We will notify you, your authorized representative and your prescribing health care provider of our decision no later than 72 hours after we receive your request. During the exception to coverage grievance process, we will cover the drug for the duration of the prescription during a standard exception request. If we approve your request, we will cover the drug until your prescription expires, including refills.

If we deny your standard non-formulary exception grievance, we will provide a written notice that will explain the denial and advise you of your rights to request an external review from an Independent Review Organization (IRO). The notice will include a toll-free number and address for the MDI.

A decision made by an IRO is binding for both us and the member with the exception of the rescission of a policy or certificate. You are not responsible for the costs associated with the external review.

Expedited Non-Formulary Exception
If you need the requested drug more urgently, we will follow our expedited non-formulary request timeline.

Urgent circumstances exist 1) when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain function, or 2) you are undergoing a current course of treatment using a non-formulary drug. When you submit your request, you must indicate that your circumstances are urgent.

We will notify you or your authorized representative and your prescribing health care provider of our decision no later than 24 hours after we receive your request. During the exception to coverage grievance process, we will cover the drug for the duration of the exigency during an expedited exception request. If we approve your request, we will cover the drug until your prescription expires, including refills.

If we deny your standard non-formulary exception grievance, we will provide a written notice that will explain the denial and advise you of your rights to request an external review from an IRO. The notice will include a toll-free number and address for the MDI.

A decision made by an IRO is binding for both us and the member with the exception of the rescission of a policy or certificate. You are not responsible for the costs associated with the external review.