How to Get Help With a Problem for MDwise Marketplace Members

Getting Help with a Problem

The quality of service you get from MDwise is important to us. If you have a concern or are not satisfied, call the MDwise customer service. You must do this within 60 days of when the problem occurred.

If you are dissatisfied with a service you receive, a MDwise customer service representative will file a grievance. He or she will try to solve your concerns right away. We will follow up with a letter within 20 business days.

In an emergency, grievances will be handled quickly. This is called an “expedited” grievance. If your case can be expedited, we will review your case and notify you of a decision within 48 hours.
 

Filing an Appeal

If you do not agree with a decision you get, you have the right to ask for further review of the problem. This is called an “appeal.”You can file an appeal about any health care decisions. Someone, like your doctor, can do this on your behalf if you want them to.

You must file an appeal within 33 days of the date that the decision was made. When you file an appeal, you may be able to continue getting a service that has been denied. This can only happen if you are getting those services already. If MDwise decides that the services will not be authorized, you will have to pay for those services. Ask us about continued services if this is important to you.
 

How to File an Appeal:

Step 1. Submit your appeal
You must write a letter. You can call the MDwise customer service department for help writing your letter. When you write a letter, you should include the following:
  • Date and description of the service that was denied.
  • Additional information that can help in our review.
  • You must sign the letter.
Keep a copy of these papers for yourself. Then, send us the original at:

MDwise Marketplace Customer Service Department
Attn: Appeals
P.O. Box 441099
Indianapolis, IN 46244-1099

Your appeal must be filed within 33 calendar days of receiving a denial letter. You may ask someone else to file an appeal on your behalf, who can be your doctor if you want them to. You may also send in written comments or information.

The MDwise Appeals Panel will review your issue. MDwise will send you a letter with the date and time the Appeals Panel will meet. You can speak to the panel if you want. You can also have someone else speak for you. This can be done in person or by telephone.
 
MDwise will send you a letter with an answer to your appeal within 25 working days from the time we receive your appeal.

You have a right to review copies of documents that are related to your appeal. This includes records that we used in making our decision such as a benefit information, state rule or guideline. Please call us if you want to review these records. We will provide copies of this information free of charge upon request.

Step 2. Request an external appeal review
You may choose (1) an external review by an independent review organization or (2) to submit a complaint to the Indiana Department of Insurance. If you choose the Independent Review Organization option first you may still submit a complaint to the Indiana Department of Insurance.


Indiana Department of Insurance

If you need the assistance of the governmental agency that regulates insurance, or have a complaint you have been unable to resolve with your insurer, you may contact the Department of Insurance by mail, phone or email.
By mail:
State of Indiana Department of Insurance Consumer Services Division
Indiana Department of Insurance
311 West Washington Street, Suite 300
Indianapolis,Indiana 46204
By phone:
Consumer Hotline 800-622-4461 or 317-232-2395.
By email: 
Complaints can be filed electronically at in.gov/idoi. There is no deadline to submit a complaint.


For an Independent Review Organization

You must request an external grievance review by an Independent Review Organization within 45 calendar days of the MDwise appeal denial letter, to:

MDwise Medical Management
Attn: Appeals
P.O. Box 441099
Indianapolis, IN 46244-1099

The decision made by the Independent Review Organization is binding and MDwise will authorize the service promptly if the decision is made in your favor.

If at any time, you have questions about the MDwise internal appeal panel process or submitting a complaint to the Indiana Department of Insurance process, please call MDwise customer service for help.
 
Step 3.
If you selected an Independent Review Organization external review and their decision is not in your favor, you may submit an complaint to the Indiana Department of Insurance. To submit a complaint to the Indiana Department of Insurance see the Indiana Department of Insurance section.

Other notes: In an emergency, appeals will be handled quickly. This is called an “expedited” appeal. If your case can be expedited, we will review your case and notify you of a decision within 72 hours. Call MDwise customer service to see if this can be done.