Appeals and grievances
As a UniCare member, you have the right to ask us to reconsider decisions we have made and to make complaints. These are called appeals and grievances.
Appeals
If you disagree with our decision about your care or services you requested, you can file an appeal. An appeal is a formal way of asking us to review and change a coverage decision we made.
You have 60 calendar days after you get a written notice from us to file an appeal.
You can do this yourself or ask someone you trust to file the appeal for you. You can call the Customer Care Center at 1-800-782-0095 (TTY 711) if you need help filing an appeal.
The appeal can be made by phone or in writing. If you call us, you must also file your appeal in writing. We can help you complete the appeal form. We will let you know in writing that we received your request for an appeal within five calendar days of receiving it.
If your appeal review needs to be expedited (reviewed more quickly than the standard time frame) because you have an immediate need for health services, you do not need to follow up in writing after you call us. We will let you know in writing that we received your request for an expedited appeal within 24 hours of receiving it.
We will not treat you any differently or act badly toward you because you file an appeal.
To file in writing, you can send your appeal to us by:
Mail:
Attn: Grievance & Appeals Department
UniCare Health Plan of West Virginia, Inc.
P.O. Box 91
Charleston, WV 25321-0091
Fax: 1-844-882-3520
To file by phone, call the Customer Care Center at 1-800-782-0095 (TTY 711).
You can also send us an appeal by filling out a
Member Appeal Request Form
and sending it to us. The
Member Appeal Representative Form
can be used if someone is submitting the appeal for you.
Before and during the appeal, you or your representative can see your case file, including medical records and any other documents and records being used to make a decision on your case.
You can ask questions and give any information (including new medical documents from your providers) that you think will help us to approve your request. You may do that in person at 200 Association Drive, Ste. 200, Charleston, WV 25311, in writing or by phone.
If you need help with understanding the Appeals process, you can contact our Community Outreach Specialists.
Standard appeals:
If we have all the information we need, we will tell you our decision in writing within 30 calendar days.
Expedited (fast track) appeals:
If we have all the information we need, we will call you and send you a written notice of our decision within 72 hours of receiving your request.
Appeals extensions:
We can ask for 14 more calendar days if we need extra time. We’ll send you a letter within two calendar days telling you why more time is needed. You may file a grievance if you’re unhappy with our request for 14 more days to complete our review.
You may also ask for 14 more days if you need more time. Upon receipt of your appeal request, you also have access to a copy of your appeal case file.
If you need more time to gather your documents and information, just ask. You, your provider or someone you trust may ask us to delay your case until you are ready. We want to make the decision that supports your best health. This can be done by calling the Customer Care Center at 1-800-782-0095 (TTY 711) or writing to:
Attn: Grievance & Appeals Department
UniCare Health Plan of West Virginia, Inc.
P.O. Box 91
Charleston, WV 25321-0091
Fax: 1-844-882-3520
Your care while you wait for a decision
When our decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we are making a decision on your appeal. You can also ask a trusted representative to make that request for you.
You must ask us to continue your services within 10 calendar days from the date of the notice that says your care will change or by the time the action takes effect. You or your approved representative may ask to continue services when you first request an appeal by calling or writing to us at the Customer Care Center phone number or address above.
If you ask us to continue services you already receive during your appeal, we will pay for those services if your appeal is decided in your favor. Your appeal might not change the decision we made about your services. When your appeal doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.
If you are unhappy with the result of your appeal, you can ask for a Fair Hearing.
If you don’t agree with a decision we made that reduced, stopped or restricted your services after you receive our decision about your appeal, you can ask for a Fair Hearing from West Virginia. A Fair Hearing is your opportunity to give more information and facts, and to ask questions about your decision before an administrative law judge. The judge in your Fair Hearing is not a part of your health plan in any way.
You can ask for a Fair Hearing within 120 calendar days from the day you hear from us about our decision about your appeal.
When you request a Fair Hearing, you can also ask for an opportunity to mediate your disagreement. Mediation is an informal voluntary process to see if we can come to an agreement on your case. You do not have to ask for mediation to receive a Fair Hearing. Mediation is guided by a professional mediator who does not take sides. If we do not reach an agreement, you can still have a Fair Hearing. You can also decide not to go through mediation and just ask for a Fair Hearing.
If you need help with understanding the Fair Hearing or Mediation processes, you can contact our Community Outreach Specialists.
If a State Fair Hearing is requested, the State will hear your case and give you a decision in writing within 90 days of the date you asked for a State Fair Hearing. If you are still not happy with the decision, you can take your case to Circuit Court. If you want to proceed in taking your case to Circuit Court, you must file within 30 days of your notice of the State Fair Hearing decision. You can file an appeal to the Bureau for Medical Services (BMS).
Send your request for an appeal to:
WV Bureau for Medical Services
Office of Medicaid Managed Care
350 Capitol St., Room 251
Charleston, WV 25301-3708
The BMS decision will be sent to you in writing. If you are not happy with the Bureau for Medical Services decision, you can appeal to the West Virginia Insurance Commissioner by sending your appeal to:
The Office of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540
Your care while you wait for a decision
When our decision reduces or stops a service you are already receiving, you can ask to continue the services your provider had already ordered while we decide your case. You can also ask a trusted representative to make that request for you.
You must ask us to continue your services within 10 calendar days from the date of the notice that says your care will change or by the time the action takes effect. You or your approved representative may ask to continue services when you first request an appeal by calling or writing to us at the Customer Care Center phone number or address above.
If you ask us to continue services you already receive during your Fair Hearing case, we will pay for those services if your case is decided in your favor. Your Fair Hearing might not change the decision we made about your services. When your Fair Hearing case doesn’t change our decision, we may require you to pay for the services you received while waiting for a decision.
Grievances
If you are unhappy with your health plan, provider, care or your health services, you can file a Complaint (also called a Grievance). You can file a complaint by phone or in writing at any time.
To file by phone, call the Customer Care Center at 1-800-782-0095 (TTY 711).
To file in writing, you can send your complaint to us by:
Mail:
Grievance & Appeals Department
UniCare Health Plan of West Virginia, Inc.
P.O. Box 91
Charleston, WV 25321-0091
Fax: 1-844-882-3520
You can also send us a complaint by filling out a
Member Grievance Form
and sending it to us.
What happens next:
We will let you know in writing that we got your complaint within five calendar days of receiving it.
We will review your complaint and tell you how we resolved it in writing within 30 calendar days from receiving your complaint.
If your complaint is about the denial of an expedited appeal, we will let you know in writing that we got it within 24 hours of receiving it. We will review your complaint about the denial of an expedited appeal and tell you how we resolved it in writing within five calendar days of receiving your complaint.
You can ask someone you trust (such as a legal representative, a family member or friend) to file the complaint for you. If you need our help because of a hearing or vision impairment, or if you need translation services, or help filling out the forms, we can help you. We will not make things hard for you or take any action against you for filing a complaint.
If you are not happy with how we resolved your issue, you can file an appeal with our Grievances and Appeals Department.