Prevea360 Health Plan Grievance & Appeals Process
We know that at times you may have questions and concerns about benefits, claims or services you have received from Prevea360 Health Plan. 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 877.230.7555. 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.
If after contacting us, you continue to feel a decision has adversely affected your coverage, benefits or relationship with Prevea360 Health Plan, you may file a grievance (sometimes called an appeal). Upon receipt of the grievance, the Grievance and Appeals Department will acknowledge your grievance within five business days. Our acknowledgment letter will advise you of your right to submit written comments, documents or other information regarding your grievance; to be assisted or represented by another person of your choice; to appear before the Grievance Committee; and the date and time of the next scheduled meeting, which will not be less than seven calendar days from the date of your acknowledgment and within 30 calendar days of receiving the grievance. If you choose to appear before the Committee, you must notify us. If you are unable to appear before the Committee, you do have the option of scheduling a conference call. Your grievance will be documented and investigated. All grievances will be resolved within 30 calendar days of receipt. You have the right to request a copy of documents, free of charge, relevant to the outcome of your grievance by sending a written request to the address listed below.
If your grievance is determined to be urgent in nature, you may be entitled to an expedited grievance which will be resolved within 72 hours of the receipt. If your grievance meets criteria for an expedited grievance, meaning your situation is deemed urgent in nature or you are receiving ongoing treatment, you are also eligible for an expedited external review concurrent with the internal expedited review if your grievance.
After the internal grievance process is completed, you may also be entitled to an independent external review (IER) if the outcome of your grievance involves care that has been determined not to meet the policy requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness of care or where the requested services are considered experimental or investigational. Pre-existing Condition determinations and Policy Rescissions are also eligible for IER. You must exhaust all appeal/grievance options before requesting an independent external review. However, if we agree with you that the matter should proceed directly to independent review, or if you need immediate medical treatment and believe that the time period for resolving an internal grievance will cause a delay that could jeopardize your life or health, you may ask to bypass our internal grievance process. In these situations, your request will be processed on an expedited basis. If you or your authorized representative wish to file a request for an independent review, your request must be submitted in writing to the address listed below and received within four months of the decision date of your grievance. Upon receipt of your request, a URAC accredited IER will be assigned to your case through an unbiased random selection process. The assigned IER will send you a notice of acceptance within one business day of receipt, advising you of the right to submit additional information. The assigned IER will also deliver a notice of the final external review decision in writing to you and Prevea360 Health Plan within 45 calendar days of their receipt of the request. A decision made by an IER is binding for both Prevea360 Health Plan and the member with the exception of pre-existing condition exclusions and the rescission of a policy or certificate. You are not responsible for the costs associated to the IER.
The Grievance and IER procedures are also described in your Member Certificate/Handbook. Please refer to this document to determine eligibility for IER rights. You may also contact our Customer Care Center at 877.230.7555 or refer to our website prevea360.com with any additional questions regarding these processes.
You may initiate the Grievance process by submitting your complaint to us in writing to:
Prevea360 Health Plan, Inc.
Attention: Grievance and Appeals Department
P.O. Box 56099
Madison, WI 53705