Wisconsin Parity Resources

For general information about filing a parity appeal for mental health or addictions services, you cannot go wrong with contacting one of the consumer advocates below. Each has years of experience helping consumers in the state of Wisconsin. Consumer Guide to Health Care – How to Deal with Problems with your Health Insurance https://www.dhs.wisconsin.gov/guide/probins.htm

When filing an appeal for the first time, you should contact your health plan’s customer service support line or check out their information online. If you choose to appeal an adverse benefit determination concerning your mental health or substance use treatment or benefits, please keep in mind that the timeframe to do so varies by state, plan type, and other factors. Contact your state’s department of insurance for additional information. Here is some contact information for Wisconsin Health Plans:

Anthem Blue Cross and Blue Shield

Contact Customer Services number found on member ID card

Common Ground Healthcare Cooperative

Contact Member Services: 877-514-2442 Written appeal requests send to: Common Ground Healthcare Cooperative-Member Services Department ATTN: Member Appeals & Grievances PO Box 1630 Brookfield, WI 53008-1630

Dean Health Plan

Refer to Chapter 9 of evidence of coverage to find information on filing grievances and determination and appeals process.

Gundersen

Call Customer Service: 608-775-8007 or 800-897-1923 Written grievance send to: Gundersen Health Plan Attn: Member Advocate 1900 South Avenue, NCA2-01 La Crosse, WI 54601

Medica

Contact Customer Service: 952-992-2457 or 1-866-810-5032 Appeal and Complaint forms can be found here.

MercyCare

Call Member Services: 800-624-3879

Prevea 360 Health Plan

Contact Customer Care Center: 877-230-7555 Grievances submitted in writing send to: Prevea360 Health Plan, Inc Attention: Grievance and Appeals Department PO Box 56099 Madison, WI 53705

Security Health

Call Customer Service: 877-998-0998

United Healthcare

Call Customer Service at the number found on the member ID card

Insurance Commissioner

Wisconsin Office of the Commissioner of Insurance Commissioner 125 South Webster Street Madison, Wisconsin 53703-3474 Toll Free: (800) 236-8517 Phone: (608) 266-3585 Fax: (608) 266-9935 ocicomplaints@wisconsin.gov

Utilization Management Appeals

Wisconsin Office of the Commissioner of Insurance Commissioner 125 South Webster Street Madison, Wisconsin 53703-3474 Toll Free: (800) 236-8517 Phone: (608) 266-3585 Fax: (608) 266-9935

External Review Appeals

Wisconsin Office of the Commissioner of Insurance Managed Care Specialist 125 South Webster Street Madison, Wisconsin 53703-3474 Phone: (608) 264-6224

Parity Appeals

Wisconsin Office of the Commissioner of Insurance Managed Care Specialist 125 South Webster Street Madison, Wisconsin 53703-3474 Phone: (608) 264-6224 Additional Wisconsin Insurance Administration Contacts, click here.

The federal government also can be a helpful resource if you are enrolled in a self-funded plan, Medicare, Medicaid or another type of insurance that is overseen at least in part by a federal agency.

For definitions and filing information refer to the Parity Resource Guide

U.S. Department of Health and Human Service’s website on the Affordable Care Act health reform law

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA)

(SAMHSA) Implementation Mental Health Parity Addiction Equity Act

U.S. Centers for Medicare and Medicaid Services (CMS)

U.S. Department of Labor, Employee Benefits, Security Administration (EBSA) or toll-free hotline: 1.866.444.EBSA (3272)

For the U.S. Department of Health and Human Services & Centers for Medicare and Medicaid Services list of exempt state and local plans, please email NonFed@cms.hhs.gov. You may ask them if any particular state and local plan has opted out of MHPAEA.

Information on requirements of employer-based insurance coverage and self-insured health plans.
EBSA has benefit advisors who are available to answer questions and provide assistance in obtaining your benefits.

Consumer Guide to Disclosure Rights: Making the Most of Your Mental Health and Substance Use Disorder Benefits

Veterans and military personnel can use these resources to get help or more information with their medical or behavioral health complaints.

Health Net Federal Services

A grievance is a written complaint or concern about a medical provider.
Click here for specific information regarding who, what and how to file.

TRICARE

View the recently released Tricare Mental Health Fact Sheet.

The appeal process is different based on the benefit issue. Depending on your issue, you can file a:

• Factual appeal
  • This is if you were denied payment for services or supplies you received, or if payment was stopped for services or supplies previously authorized.
• Medical necessity appeal
  • This is if prior authorization for care or services was denied because it was not deemed medically necessary. Medically necessary means it must be appropriate, reasonable, and adequate for your condition.
• Pharmacy appeal
  • This is if you don’t agree with a decision made about your pharmacy benefit. For example, Express Scripts denies your pharmacy claim.
• Medicare-TRICARE appeal
  • This is if you’re eligible for both TRICARE and Medicare, and Medicare denies your services or supplies.

If your care is denied, you should receive a letter with details about how to file your appeal.

Veterans Health Administration

Complaints are initially handled through the Patient Advocate.
Patient Advocate can be contacted at your local VA Medical Center.

If you have any additional questions about parity compliance, please contact info@paritytrack.org