Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.


Coverage Decisions and Appeals
The plan makes coverage decisions about your benefits and coverage or about the amount we will pay for your medical services or drugs. You ask us for a coverage decision whenever you go to a doctor for medical care if you want to know if we will cover a medical service before you receive it. In some cases, we might decide the services are not covered for you. Or we may decide it is time to stop covering services you have been receiving. If you disagree with this coverage decision, you can make an appeal.

If our plan makes a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking our plan to review and change a coverage decision we have made. When you make an appeal, our plan reviews the coverage decision we have made to check to see if our plan was being fair and following all of the rules properly. When we have completed the review, we give you our decision.

When to ask for a Coverage Decision for Medical Services (Part C) If you are in any of the following situations you ask for a medical coverage decision:

 

You, your prescribing physician, or someone you name may ask us for a coverage decision or file an appeal. The person you name would be your appointed representative. You may name a relative, friend, advocate, doctor or anyone else to act on your behalf. You and that person must sign and date a statement that gives the person legal permission to be your appointed representative. The Appointment of Representation form can be found below. This form gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. Click here to download a representative form:
Appointment of Representation Form

How to ask for a Medical (Part C) Coverage Decision
You can ask for a decision about Part C (medical care) coverage on one of the following ways:
Call:Click here for the correct phone number for your plan and state
Fax: 1-813-262-2802
Write: WellCare, Coverage Determinations -Medical, P.O. Box 31370 Tampa, FL 33631

When to ask for a Coverage Decision for Drugs (Part D)
If a drug is not covered in the way you would like it to be covered, you can ask the plan to make an “exception” to our coverage rules (coverage decision). When you ask for an exception to our Part D drug coverage rules, your doctor will need to explain the medical reasons. We will then consider your request. Here are three examples of exceptions that you or your doctor can ask us to make:

1.You can ask is to cover a Part D drug that is not on our plan’s List of Covered Drugs (Formulary).(We call it the “Drug List” for short.) Please note you cannot ask for coverage of any “excluded drugs” or other non-Part D drugs that Medicare does not cover. You will need to pay the cost-sharing amount that applies.

2.You can ask us to remove a restriction on the plan’s coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on the plan’s List of Covered Drugs.

3.You can ask us to cover a drug to a lower cost group.This would mean a lower co-payment or coinsurance.

Who can ask for an exception?
You or your doctor or someone else who is acting on your behalf can ask for an exception to our rules for coverage of your Part D drugs. Your doctor or other prescriber must give us give us a written statement that explains the medical reasons for requesting an exception for the drug exception you are requesting. (We call this the “doctor’s statement.”) Your doctor or other prescriber can fax or mail the statement to our plan, or can speak to us on the phone and follow up by faxing or mailing the signed statement.

How to ask for a Drug (Part D) Coverage Decision
You can ask for a decision about Part D (prescription drugs) coverage on one of the three following ways:
Call: Click here for the correct phone number for your plan and state
Fax: 1-866-388-1767
Write: WellCare, Pharmacy-Coverage Determinations, P.O. Box 31577, Tampa, FL  33631-3577

Overnight Address: WellCare, Pharmacy-Coverage Determinations, 8735 Henderson Road, Ren. 4, Tampa, FL 33634

These forms can help you ask for a coverage decision:
WellCare Injectable Infusion Form
Medicare Part D Coverage Determination Request Form

When should I file an appeal? You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you of our coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

You can ask for a fast decision

You have the right to ask for fast (expedited) decisions on coverage and appeals. You would ask for a fast decision if waiting for the standard timeframe would endanger your like or health or ability to regain maximum function. You, your doctor, or your representative may ask us for a fast appeal by calling, faxing, or writing us at the numbers or address listed below.

Generally we use the standard decision deadlines for giving you our decision unless we agree to use the fast deadlines. A standard decision means we will give you an answer within 14 days after we receive your request. A fast decision means we will give you an answer within 72 hours.

How can I file an appeal?
There are three ways to file an appeal:
Call:Click here for the correct phone number for your plan and state
Fax: 1-866-201-0657
Write: WellCare, Appeals Department, P.O. Box 31368, Tampa, FL 33631-3368

Overnight Address: WellCare, Appeals Department, 8735 Henderson Road, Ren. 4, Tampa, FL 33634

You may download the following forms to use for your appeal:
WellCare Medicare Redetermination (Appeal) Request Form
WellCare Provider/Physician Appeal Form

Independent Review Organizations; also known as Independent Review Entity (IRE)

If our plan says no to your appeal, your case will automatically be sent to the next level of the appeals process to make sure that we were being fair. We are required to send your appeal to the Independent Review Organization. The IRE is an outside independent organization that is hired by Medicare. This organization will review your appeal and decides whether the decision our plan made should be changed.

Member complaints/grievances
The formal name for “making a complaint” is “filing a grievance.”  A grievance is a complaint you can file when your concern is about something other than benefits coverage. For example, you would file a grievance if you have a problem about the quality of care, customer service, waiting times for care or the behavior of the plan’s or a provider’s staff.

Who can file a grievance?
You can file a grievance or someone you authorize can do so on your behalf. You may download this form to appoint someone to act as your representative:
Appointment of Representation Form

When should I file a grievance?
Here are some issues that may prompt you to file a grievance:
 

Your health and satisfaction are important to us. Usually calling our Customer Service at the number listed at the top of this page is the first step when you have a problem or concern. If you do not wish to call you can put your complaint in writing and send it to us. You may file a grievance within 60 calendar days of the date of the event that is causing your complaint.

You can ask for a fast grievance
A standard grievance is resolved within 30 days from the date of submission. If we need more information and the delay is in your best interest, we can take up to 14 more days (44 days total) to answer your complaint.

If you are making a complaint because we denied your request for a “fast response” to a coverage decision or appeal, we will automatically give you a “fast complaint.” If you have a fast complaint, we will give you an answer within 24 hours.

How do I file a grievance?
You file a grievance in one of the three following ways:
Call: Click here for the correct phone number for your plan and state
Fax: 1-866-388-1769
Write: WellCare, Grievance Department, P.O. Box 31384, Tampa, FL 33631-3384

If you would like information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with our plan, click here for the correct phone number for your state

Quality Improvement Organizations (QIO)
If you prefer, you can also make complaints about quality of care to the Quality Improvement Organizations (QIO) (without making the complaint to our plan). To find the name, address, and phone number of the Quality Improvement Organization in your state, please click here or read your Evidence of Coverage. If you make a complaint to this organization, we will work together with them to resolve your complaint.

For more information please click Evidence of Coverage. See the section titled “What to do if you have a problem or complaint.”