Grievance Procedure

All health insurance plans, including all managed care plans are required to have an internal grievance procedure for those who are not satisfied with the service they receive. The procedure must be set forth in the insurance contract and must also be provided in written notice.

The managed care plan must provide each enrollee with complete and understandable information about how to use the grievance procedure. An enrollee has the right to appear in person before the grievance committee and present additional information.

Enrollees may wish to first contact the managed care plan with a question or complaint. Many complaints can be resolved quickly and require no further action. However, filing a complaint with the plan first is not required. An enrollee can file a complaint with the appropriate state agency instead of, before, or at the same time as filing with the managed care plan.

Managed care plans are required to have a separate expedited grievance procedure for situations where the medical condition requires immediate medical attention. The procedure requires managed care organizations to resolve an expedited grievance within 72 hours after receiving the grievance.

Managed care plans are required to file a report with OCI listing the number of grievances they had in the previous year. A summary of this information for HMOs is included in The Consumer's Guide to Managed Care Plans in Wisconsin. To receive a copy of this brochure call 1-800-236-8517. A copy is available on OCI's Web site at http://oci.wi.gov/pub_list/pi-044.htm.