Members Rights and Responsibilities
As a member of WPS Health Insurance, we believe you have certain basic rights and responsibilities regarding your health care.
You Have the Right To:
- Be treated with respect and recognition of your dignity and your right to privacy. You also have the right to the privacy of your medical information unless you allow the release of such information.
- Participate in any decision making regarding your health care.
- Have a candid discussion of appropriate or medically necessary treatment options for your medical condition.
- Receive the right care at the right level at the right time by the right type of provider for your medical condition.
- Receive information about preventive health care that is age and sex specific, and information about remaining as healthy as possible including self care and maintenance care for specific chronic diseases.
- Receive care according to federal and state mandates.
- Voice complaints or appeals about service from WPS Health Insurance or about care received.
You Have the Responsibility To:
- Provide, to the extent possible, information WPS Health Insurance and your physician or health care provider need to care for you.
- Be aware of your health care coverage and requirements/limitations under your certificate of coverage, including , but not limited to, pre-certification or preauthorization requirements and exclusions.
- Ask questions about your diagnosis, your treatment plan — and how to best manage your health.
- Follow the plans and instructions for care on which you have agreed with your physician or other health care provider.
Certain federal and state laws require that we disclose the following information to you regarding your benefits.
If we deny a claim and you do not agree, you can ask for a review of this decision. This is called either a grievance or an appeal. If you have coverage under a certificate or policy subject to Wisconsin Insurance law, your written dissatisfaction with our benefit determination is usually referred to as a "grievance." If
you are covered under a self-funded health benefit plan that is subject to ERISA, your written dissatisfaction with our benefit determination is usually referred to as an "appeal." Please
use the grievance and appeals procedures, as applicable, described in your certificate, policy, or benefits booklet for a full description of your rights under state and/or federal law.
Our grievance and appeal process is described below:
- You may submit written comments, documentation, records, or other information relating to the benefit decision in question.
- You may request copies of all information we have in our files relevant to our benefit decision.
- For decisions regarding medical judgment, we will consult with a health care professional with expertise in the relevant medical field.
- You may request, free of charge, the identity of any health care professional whose opinion we obtained in connection with our decision.
- If you are filing an appeal, your appeal must be submitted to us within 180 calendar days from the date you receive written notice of our claim decision as required by ERISA. You might have more time to appeal if your plan certificate/booklet provides additional time.
- If you are filing a grievance, your grievance must be filed within three years of the date of the claim denial or of the date the incident on which the grievance is based took place.
- We will send you a written notice that we received your grievance or appeal within five business days of our receipt of it.
- We will notify you of the date your grievance or appeal will be heard and whether you have the right to attend that meeting. You may designate a representative to act for you by completing and sending your written authorization to us along with your grievance or appeal.
- If we had to approve your claim before you received care (i.e., prior authorization), we will notify you of our decision within 30 days of receiving your grievance or appeal.
- For most grievances or appeals, we will notify you of our decision as soon as possible, but not later than 60 calendar days after our receipt of your grievance or appeal.
- If you have coverage under a Medicare supplement plan, we will notify you of our decision within 30 calendar days of our receipt of your grievance. Under some circumstances, we may extend our review for an additional 30 calendar days. If so, we will notify you in writing of the expected completion date and the reason for the delay.
- For certain grievances or appeals involving coverage of experimental treatment, we will notify you of our decision within 30 calendar days of our receipt of your grievance or appeal.
- If you or your physician feel that your life or health could be seriously jeopardized during the time it takes us to complete the grievance or appeal timeframes specified above, you may have the right to an expedited grievance or urgent appeal. All expedited grievances and urgent appeals will be handled as quickly as the health condition requires but no later than 72 hours from the time we receive your expedited grievance or urgent appeal request.
- To file an expedited grievance or urgent appeal, you or a health care professional with knowledge of your medical condition must submit the expedited appeal or urgent grievance orally via telephone or in writing via mail or fax using the contact information below. If you contact us initially by phone, you or a health care professional will need to submit copies of any supporting documents via mail or fax.
For all other grievances or appeals (not urgent or expedited), please explain the specific reason(s) you disagree and mail, fax, or deliver the written grievance or appeal with copies of any supporting documents to the address below:
WPS Health Insurance
1717 W. Broadway –P.O. Box 7062
Madison, WI 53707-7062
Phone: 800-765-4977 (toll-free)
Fax Number: 608-977-9920
If we continue to deny payment, coverage, service requested, or you do not receive a timely decision, you may be able to request an independent external review.
Independent Claims Review
The independent claims review process provides you with an opportunity to have an independent review organization review your claim dispute.
The Health Insurance Portability and Accountability Act (HIPAA) is designed to make health coverage more portable for individuals who change jobs or health plans by limiting the coverage exclusions that can be imposed when such a change occurs.
HIPAA also contains privacy provisions designed to protect the confidentiality and security of Protected Health Information (PHI).
The Employee Retirement Income Security Act (ERISA) is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows a qualified beneficiary (e.g., a covered employee, spouse, and/or dependent), who loses group health coverage due to a qualifying event, to elect, within the election period, to continue group health coverage for a period of time on a self-pay basis.