Getting Help with a Problem
The quality of service you get from MDwise is important to us. If you need help with a problem or are not satisfied, you can call MDwise Customer Service at 1-800-356-1204. MDwise members can also submit questions or complaints through the myMDwise Member Portal. This includes accessibility issues, provider directory errors, in addition to general concerns. 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 30 calendar 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 may 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 may write a letter or call Customer Service to request an appeal. You can call the MDwise customer service department for help writing your letter. Your letter you should include the following:
- Your name, address, telephone number and MDwise identification number ending in 99
- Date and description of the service that was denied
- The reason you are appealing
- Any other information you feel may be helpful in the 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
Phone number: 317-630-2831 or 1-800-356-1204
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.
MDwise will send an acknowledgement letter within three business days after receiving the appeal. 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. Participation in the Appeal Panel can be done by telephone. MDwise will send you a letter with an answer to your appeal within 30 calendar days from the time we receive your appeal. If we need more time to review the problem, we will write to you and let you know.
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.
If you receive a denial for services, you are already getting, you may be able to continue getting those services if you appeal within ten (10) days of MDwise notice or the intended effective date, whichever is later. You may have to pay for those services if the first decision isn’t changed. Please call MDwise about continued services if this is important to you.
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 48 hours. Call MDwise customer service to see if this can be done.
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 and/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 120 business days of the MDwise appeal decision letter. To request a State Fair Hearing, you must contact the State directly and in writing at:
Office of Administrative Law Proceedings
402 W. Washington St., Room E034
Indianapolis, IN 46204-2273
The State Office of Administrative Law 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 120 calendar days of the MDwise appeal denial letter, to:
MDwise Customer Service Department
Attn: Appeals
P.O. Box 44236
Indianapolis, IN 46244-0236
Phone number: 317-630-2831 or 1-800-356-1204
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 120 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, IRO reviews may be handled quickly. This is called an “expedited” review. If your case can be expedited, the IRO will review your case and notify you of a decision within 72 hours. Call MDwise customer service to see if this can be done.