COMPLAINT AND GRIEVANCE PROCEDURES
Common Ground Healthcare Cooperative (CGHC) maintains an internal process for the timely investigation and resolution of complaints and grievances. Members may file a complaint/grievance regarding any aspect of care or service provided to them by CGHC and/or their contracted providers. The internal complaint/grievance process includes steps to ensure careful and complete consideration is given to each complaint/grievance while attempting to be as expeditious as possible.
A complaint is any expression of dissatisfaction expressed to us by a member, or a members authorized representative, about us, our providers with whom we have direct or indirect contracts, or any of our vendors who provider services. We take all member complaints seriously and are committed to responding to them in an appropriate and timely manner. Some examples of
- Wait time in a doctor’s office
- Claims practices
- Quality of your healthcare
If you have a complaint regarding any aspect of care or any authorization decision made by CGHC, please contact Member Services at 1-877-514-2442.
A grievance is dissatisfaction with the provision of services or claims practices that is expressed in writing to CGHC by, or on behalf of, a member. If the dissatisfaction is regarding a denial or adverse determination, this is considered an appeal and follows the appeal process. CGHC will send you an acknowledgement letter within five (5) business days of receipt of the grievance. Grievances are investigated including any aspect of clinical care involved. This may include, but is not limited to, a request for medical records or a provider response. CGHC will resolve the grievance within thirty (30) days unless an extension is needed.
APPEALING A DENIAL OF SERVICE
If an authorization has been denied, you have the right to appeal that decision. CGHC must complete the appeals process within thirty (30) calendar days. If CGHC is unable to complete your appeal within the thirty (30) day timeframe, a fourteen (14) calendar day extension may be requested. A letter will be sent notifying you of the reason for the extension and the anticipated date of completion.
If you are appealing the denial of services, or the reduction of services you are getting right now, you may continue to get these services while you appeal but if the appeal decision is not in your favor, then you may be responsible to pay for those services.
EXTERNAL REVIEW BY CERTIFIED INDEPENDENT REVIEW ORGANIZATION
You may request an external review in writing to CGHC within four (4) months from the date the internal appeal process was completed.
The request for external review must be made in writing and sent to:
Common Ground Healthcare Cooperative – Member Services Department
ATTN: Member Appeals & Grievances
P.O. Box 1630
Brookfield, WI 53008-1630
You have the right to skip the internal appeal process and proceed directly to external review if you prefer.
EXPEDITED APPEAL PROCESS:
- A request for an expedited resolution to an appeal may be submitted orally, in writing or by electronic means by the member or the provider/practitioner acting on behalf of the member.
- An expedited appeal review will be provided in response to an oral or written request when CGHC determines that allowing the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum functions. Such a determination is based upon a request from the member, a provider’s support of the request, a
provider’s request on behalf of a member or CGHC independent determination.
- CGHC will grant expedited review for all requests concerning admissions, continued stay, or healthcare services for a member who has receive emergency services but has not been discharged from the facility.
- CGHC shall resolve the appeal within seventy-two (72) hours from receipt of the request for an expedited appeal utilizing the standard appeal process. The member and the provider will be notified orally and in writing by the Appeals Department.
- If a request for an expedited appeal is denied, the appeal is placed in a thirty (30) calendar day timeframe for standard resolution. The thirty (30) day period will begin on the date the expedited request was denied.
- An expedited external review can be requested concurrently to the internal appeal process.
OFFICE OF THE COMMISSIONER OF INSURANCE
You may resolve your problem by taking the steps outlined above. You may also contact the Office of the Commissioner of Insurance, a state agency which enforces Wisconsin’s insurance laws, and file a complaint.
You can contact the Office of the Commissioner of Insurance by writing to:
Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873
Or you can call 608.266.0103 or toll free at 1-800-236-8517, and request a complaint form.