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Filing an Appeal

How will I find out if services are denied or limited? What can I do if my doctor asks for a service for me/my child that’s covered, but MHS Health Wisconsin denies or limits it?

MHS Health will send you a letter if a requested service is denied or limited. If you disagree with the decision, you may file an appeal.

When do I have the right to ask for an appeal?

You have the right to appeal if you believe your benefits are wrongly denied, limited, reduced, delayed, or stopped by MHS Health. Your authorized representative or your provider may request an appeal for you if you have given them consent to do so. When requesting an appeal, you must appeal to your HMO Program, MHS Health, first. The request for an appeal must be made no more than 60 days after you receive notice of services being denied, limited, reduced, delayed, or stopped.

If you disagree with your HMO’s decision about your appeal, you may request a fair hearing with the Wisconsin Division of Hearing and Appeals. The request for a fair hearing must be made no more than 90 days after your HMO/PIHP makes a decision about your appeal.

If you want a fair hearing, send a written request to: Department of Administration, Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707-7875. The hearing will be held with an administrative law judge in the county where you live. You have the right to be represented at the hearing, and you can bring a friend for support. If you need a special arrangement for a disability or for language translation, please call 1-608-266-3096 (voice) or 1-608-264-9853 (hearing impaired).

Can someone from MHS Health help me file an appeal?

If you need help writing a request for an appeal, please call your HMO Advocate at 1-800-713-6180, the BadgerCare Plus and Medicaid SSI Ombuds at 1-800-760-0001, or the HMO Enrollment Specialist at 1-800-291-2002. If you are enrolled in a Medicaid SSI Program, you can also call the SSI External Advocate at 1-800-708-3034 for help with your appeal.

What are the timeframes for the appeals process?

You will have sixty (60) days from the date of the denial letter to appeal the decision. MHS Health will acknowledge your appeal within ten (10) days of receipt, and complete the appeal within thirty (30) days. This process can be extended up to fourteen (14) days. If more time is needed to gather facts about the requested service, you will receive a letter with the reason for the delay.

You may request to have the disputed services continued while the HMO appeal and State fair hearing process are occurring. The request to continue services must happen within 10 days of receiving the notice that services were denied or changed, or before the effective date of the denial or change in benefits. You may need to pay for the cost of services if the hearing decision is not in your favor.

You will not be treated differently from other members because you request an appeal or a fair hearing. Your health care benefits will not be affected.