Members Rights and Responsibilities
As a member of WPS, 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 or about care received.
You Have the Responsibility To:
- Provide, to the extent possible, information WPS 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.
If you disagree with our benefit determination or feel that a decision has adversely affected your coverage, benefits, or relationship with WPS, you can ask for a review of this decision by submitting a written grievance/appeal. If you have coverage under an individual or fully insured group plan, your written dissatisfaction 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 refer to the grievance/appeal 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/appeal process is described below:
- Appeals must be submitted to us within 180 calendar days from the date you receive written notice of our benefit decision as required by ERISA. You might have more time to appeal if your plan certificate/booklet provides additional time.
- Grievances must be filed within three years of our written notification of the benefit denial or of the date of the incident on which the grievance is based .
- You may submit written comments, documentation, records, or other information relating to your grievance/appeal.
- You may designate a representative to act for you by completing the Authorized Representative Form for Grievance/Appeal and sending it to us with your grievance/appeal.
- You may request copies of all information we have in our files relevant to your grievance/appeal.
- 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.
- We will send you a written notice that we received your grievance/appeal within five business days of our receipt.
- We will notify you of the date your grievance/appeal will be reviewed by the Grievance/Appeal Committee. You may appear in person or by phone at the grievance/appeal meeting to present information and/or ask questions.
- For most grievances/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/appeal. However, we will notify you of our decision within 30 days of receiving your grievance/appeal if:
- We have to approve coverage before you receive care (i.e., prior authorization);
- You have coverage under a Medicare supplement plan; or
- You have coverage under a fully insured plan and your grievance relates to coverage of an experimental treatment.
- If we are unable to notify you of our decision within the time frames stated above, we will notify you in writing of the expected resolution date and the reason for the delay.
- 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/appeal time frames specified above, you may have the right to an expedited grievance/appeal.
- All expedited grievances/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/appeal request.
- To file an expedited grievance/appeal, you or a health care professional with knowledge of your medical condition may submit the expedited grievance/appeal orally or in writing 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 written grievances/appeals, please explain the specific reason(s) you disagree and submit copies of any supporting documents to the address or fax number below:
WPS Health Insurance
P.O. Box 7062
Madison, WI 53707-7062
Phone: 800-765-4977 (toll-free)
WPS Health Plan, Inc.
P.O. Box 11625
Green Bay, WI 54307-1625
Phone: 920-490-6987 or 877-897-4123 (toll-free)
If your grievance/appeal is denied, you may have an opportunity to request an independent external review through an independent review organization.
Independent External Review
If we continue to deny payment, coverage, service requested, or if you do not receive a timely decision, you may be able to request an independent external review.
The independent external review process provides you with an opportunity to have an independent review organization review your dispute involving medical judgment.
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.