What is an appeal?
An appeal is a request for a review of a decision made by Western Wisconsin Cares. For example, you can file an appeal if your care team denies a service or support you requested. Other examples are decisions to reduce or end a service, or to deny payment for a service.
Who can file an appeal on my behalf?
Your authorized representative, such as a legal guardian or activated power of attorney for health care, can file an appeal for you. Your family, a friend, or a provider can file an appeal for you if they have your written permission.
What types of issues can I appeal?
You have the right to file an appeal if Western Wisconsin Cares:
- Decides to stop or reduce an authorized service you are currently getting.
- Decides to deny a service you asked for and that service is in the Family Care benefit package.*
- Decides not to pay for a service that is in the benefit package.*
If we take one of the actions listed above, we must send you a “Notice of Action”. The Notice of Action includes the date we plan to stop or reduce your services. The Notice of Action also includes information on your options for appealing and the timeframe to file an appeal.
*NOTE: Family Care provides the services in the benefit package. If you ask for a service that is not in the benefit package, Western Wisconsin Cares does not have to provide or pay for the services. We will consider your request, but if we deny it, you cannot appeal our decision. We will send you a letter to notify you that the service you requested is not in the benefit package.
You can also file an appeal if you do not like your care plan because it:
- Does not support you to live in the place where you want to live
- Does not provide enough care, treatment, or support to meet your needs and identified outcomes
- Requires you to accept care, treatment or support items you do not want or you believe are unnecessarily restrictive
or if Western Wisconsin Cares fails to:
- Arrange or provide services in a timely manner.
- Meet the required timeframes to resolve your appeal.
For more information about the appeal process and how to appeal a decision related to eligibility refer the Member Handbook starting on page 41.