Members

Grievances and Appeals

Community Care is committed to providing quality service to our members, but there may be a time when you have a concern. As a member, you have the right to file a grievance or appeal a decision and to receive a prompt and fair review.

If you are unhappy with your care or services, you should discuss it with your team first. This is usually the easiest and fastest way to address your concerns. Your team will work with you to try to find a satisfactory solution to your problem.

If you do not want to talk with your team, you can contact a Member Rights Specialist. The Member Rights Specialist can tell you about your rights and try to informally resolve your concerns.

Member Rights Specialist
Toll Free: 1-866-992-6600
TTY: Call Wisconsin Relay System at 711
Fax: 262-827-4044

Send us a secure email to ensure that information remains private. Send this secure email  to [email protected].


Member Grievance and Appeal Process

You have the right to file a grievance or an appeal or ask for a coverage determination or an organization determination about your medical care, long-term care, Part D prescription drugs, over-the counter- drugs or quality of care. 

If you are unable to resolve your concerns by working with your team or a Member Rights Specialist, you have several ways to address your concerns.  You can:

  • File a grievance and appeal with Community Care by calling the Member Rights Specialist at the numbers above or write to Community Care at:

    Member Rights Specialist
    205 Bishop's Way
    Brookfield, WI 53005

    The Member Rights Specialist can help you file a grievance or appeal and will work with you throughout the entire grievance or appeal process to try to find a workable solution.

  • File an appeal with the Wisconsin Department of Health Services (DHS). A member must file a local appeal with Community Care prior to an appeal with DHS. 
  • Ask for a State Fair Hearing with the Wisconsin Division of Hearings and Appeals (DHA).

If you have Medicare, you can also get help and information from Medicare:

  • You can call 800-MEDICARE (800-633-4227) 24 hours a day, 7 days a week. TTY users should call 877-486-2048
  • You can visit the Medicare website at https://www.medicare.gov/. (Note: clicking this link will take you to a different website.)
  • Medicare Complaint Form (Note: clicking this link will take you to a different website.)

All of the processes have been approved by Medicaid and/or Medicare. Each process has a set of rules, procedures and deadlines that must be followed by Community Care and by you to ensure that we handle grievances and appeals fairly and promptly.

 

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