How to Get Help with a Problem for Hoosier Healthwise and HIP 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 60 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 Customer Service Department
Attn: Appeals
P.O. Box 44236
Indianapolis, IN 46244-0236
Your appeal must be filed within 60 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
If you do not agree with the MDwise Appeal Panel decision, you may request an external appeal review. There are two options for an external appeal review. You may choose (1) an external review by a State fair hearing panel or (2) an external review by an Independent Review Organization. If you choose the Independent Review Organization option first, you may still request a State Fair Hearing if the Independent Review Organization upholds the denial.

For a State Fair Hearing

You must request the State fair hearing within 60 business days of the MDwise appeal decision letter. To request a State fair hearing, you must contact the State directly and in writing at:
Indiana Family and Social Services Administration
Office of Family Resources
402 W. Washington St. RM W392
Indianapolis, IN 46204
Attn: Hearing and Appeals
The State fair hearing department will respond to you directly regarding your request. You can choose to attend the State fair hearing yourself or send a representative on your behalf. Once a decision is made, you will be notified of the outcome. If the State fair hearing finds in your favor, MDwise will authorize the denied services promptly.

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 441423
Indianapolis, IN 46244
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 either the State fair hearing and/or Independent Review Organization 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 then request a State fair hearing panel. You must request the State fair hearing within 60 business days of the MDwise appeal decision letter.

To request a State fair hearing, see “For a State Fair Hearing” 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.