GENERAL INFORMATION

Grievance and Appeal

Most problems can be solved by your Community Family Care Team. If you have a problem, we encourage you to first call your Team at toll free at 1-800-842-1814 or TTY 715-838-2900. If you do not want to talk with your Team, you can call our Grievance and Appeals Coordinator. We will try to resolve any problem that you might have over the phone. If the problem is not solved following your discussion with the Team, you have the right to file a grievance or appeal.

Grievance

A grievance is a type of complaint that a member can make about Community Family Care or one of our providers. This type of complaint does not involve payment or coverage disputes.

• Examples:
• Quality of care or services
• Behavior of provider or employee
• Failure to respect your rights

Appeal

An appeal is a type of complaint a member makes when they want Partnership to reconsider or change a decision we have already made.

Examples:

• Denial or limited authorization of a requested service
• Reduction, suspension or termination of a previously authorized service
• Denial, in whole or part, of payment for a service
• Does not provide service or item included in care plan in a timely manner
• Failure of Community Family Care to act within the timeframes provided
• Develops a care plan that is not acceptable

Grievance and Appeal Process

You or someone you name to act for you (your appointed representative) may request an appeal. You can name a relative, friend, advocate, attorney, provider, or someone else to act for you. Others may already be authorized under State law to act for you. You can file a grievance or appeal as soon as possible if you do not agree with a Community Family Care Action. You must submit your grievance or appeal no more than 45 days after you receive a Notice of Action. You can request an expedited resolution of an appeal if you feel that your health or life is in jeopardy as a result of the Action, and Community Family Care has three working days to offer a resolution. A grievance can be filed orally or in writing. An appeal can be filed orally but, unless the appeal is expedited, must be followed by a written appeal.

We encourage you to initially contact your Community Family Care Team, but you can file a grievance or appeal with the Community Family Care Appeal and Grievance Committee and if you don’t agree with the decision you can still file an appeal with the Department of Health and Family Services or with the State Fair Hearing. You can also file directly with the Department of Health and Family Services, and in many cases go directly to State Fair Hearing.

Community Family Care: You can contact the Grievance and Appeals Coordinator for additional information and/or assistance regarding the process for filing an appeal or grievance. The Grievance and Appeals Coordinator can be reached Toll Free at 800-842-1814 or TTY 715-838-2900.

Community Family Care
Grievance and Appeal Coordinator
2240 EastRidge Center
Eau Claire, WI 54701

Department of Health and Family Services: You or your representative can request the Department of Health and Family Services review an appeal or grievance by contacting the Family Care Grievance hotline in writing, by telephone, or by e-mail.

DHFS Family Care Grievances
c/o MetaStar
2909 Landmark Place
Madison, WI 53713
Toll Free: 888-203-8338
Fax: 608-274-8340
E-Mail: famcare@dhfs.state.wi.us

State Fair Hearing: You or your representative can request a State Fair Hearing with the Division of Hearings and Appeals, which has its own guidelines. You or your legal representative can file for a State Fair Hearing by sending your request in writing to:

Family Care Request for Fair Hearing
c/o DOA Division of Hearings and Appeals
PO Box 7875
Madison, WI 53707-7875
Phone: 608-266-3096
TTY: 608-264-9853
Fax: 608-264-9885

Community Family Care has a grievance and appeal committee whose primary purpose is to review and resolve any formal grievance or appeal that is brought to them. You or your representative will be notified of the review and may present additional information or appear before the committee. The Grievance and Appeal Coordinator can assist with making these arrangements. A few of the pieces involved in this process are:

• Staff may be asked for information pertinent to a formal grievance or appeal
• Grievances and appeals are maintained in a confidential manner
• You, your authorized representative and your provider are free from discrimination or retaliation if exercise your right to file a grievance or appeal
• You or your authorized representative determine if you want to initiate the grievance and appeal process

Community Family Care will continue your current services until a decision is made about your appeal or grievance under the following conditions:
You file the grievance or appeal before the date of intended action or within 14 days of receipt of the written notice from Community Family Care and/or the Department of Health and Family Services (whichever is later)

• AND the current level of services was authorized by your Team
• AND you request your services to continue by contacting your Team or the Grievance and Appeals Coordinator at 715-838-2900.
• If you request your services to continue and the final decision of the grievance or appeal is not in your favor you may be required to pay for the services.

Please refer to your Community Family Care Member Handbook for more details.

Important Instructions & Forms

The form documents below are Portable Document Format (PDF) files This format requires the free Adobe® Acrobat® Reader® software to open the file. It you do not have it installed on your computer, you can visit Adobe.com and download Adobe Acrobat Reader.

• Instructions for Member Request for Appeal or Grievance Form
• Member Request for Appeal or Grievance Form