The following is an overview of the Physicians Plus Insurance Corporation Appeal Process, details can be found in your Medical Certificate. If you have any questions please contact our Member Service department at (608) 282-8900 or (800) 545-5015.
Complaint
Situations might occasionally arise when you question or are unhappy with some aspect of the service you received through Physicians Plus. Since most questions about benefits and plan operations can normally be resolved on an informal basis, we encourage you to first try and resolve the problem with the appropriate physician, staff member or by calling our Member Service department at (608) 282-8900 or (800) 545-5015. Your complaint will be documented and investigated. If your complaint is not resolved to your satisfaction, you or an authorized representative may file a grievance with Physicians Plus.
Grievance
A grievance is any dissatisfaction with services provided by, or claims practices of, Physicians Plus that is expressed in writing to Physicians Plus by or on behalf of you. If you want to submit a grievance, please submit it in writing, along with any pertinent documentation, to:
Physicians Plus Insurance Corporation
Appeal Administrator
22 East Mifflin Street, Suite 200
PO Box 2078
Madison, WI 53701-2078
You (or your authorized representative) will have the right to participate in the Grievance Committee meeting in person or by teleconference to present written and/or oral information. If you choose to participate (or have your authorized representative participate) in the Grievance Committee meeting, you must notify Physicians Plus no less than four business days prior to the date of the hearing.
If a person is acting as your authorized representative in the grievance process, Physicians Plus may require written evidence of the representative’s authority to act on your behalf.
Expedited Grievance
If your grievance or complaint is regarding a situation where if delayed the delay might seriously jeopardize the life or health of our member, our review will be expedited as medically indicated and take no more than 72 hours from the time received to render a decision. The Grievance Committee may not formally meet to review expedited grievances.
Independent Review Process
You may be entitled to an independent review of a final adverse determination involving care that has been determined not to meet Physicians Plus requirements for medical indicated, appropriateness, health care setting, level of care, effectiveness of care received or experimental treatment or services.
Please contact the Physicians Plus Grievance Administrator within 120 days (4 months) after receiving notice of a denial at (608) 282-8900 or (800) 545-5015, for information regarding filing fees, and the process of initiating this type of review.
For more information on Independent Review, including a list of certified Independent Review Organizations click here.
Office of the Commissioner of Insurance (OCI)
You may resolve your concern by taking the steps outlined above. You may also contact the Office of the Commissioner of Insurance (OCI), a state agency that enforces Wisconsin's insurance laws, and file a complaint. You may contact OCI by writing to:
Office of the Commissioner of Insurance
Complaints Department
125 South Webster Street
PO Box 7873
Madison, WI 53707-7873
You may call (608) 266-0103 in Madison or (800) 236-8517 outside of Madison to request a complaint form, or go to the OCI website at www.oci.wi.gov.
Employee Retirement Income Security Act (ERISA)
You also may have a right to bring a civil action under ERISA 502(a) if you file an appeal and your request for coverage or benefits is denied following review. ERISA has established timelines that limit filing an appeal. Appeals must be filed no more than 180 days from the date of the initial denial. Please contact your employer for more information on your rights under ERISA (ERISA does not apply to State, ETF or Non-Group plans including Medicare Supplement).
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