You have the right to appeal if you receive a denial from MDwise. An example of such a decision may be a denial of coverage or services. You will receive a letter with the decision and your right to appeal. This letter will also include the steps to start an appeal. You can ask someone like your doctor to help you.
How to File an Appeal:
Step 1. Submit your appeal.
You may file a grievance at any time. You may send us a letter or appeal over the phone.
You may call MDwise customer service at 1-800-356-1204 (TTY/TDD: 711) to submit the Service Appeal or if you need help in writing the letter or during any other steps in the process. MDwise can assist you with completing forms. MDwise has aids and services, such as interpretation services, available to you during any steps of the appeal process.
If you send a letter, it should include the following:
- Your name, address, telephone number and MDwise identification number ending in 99
- What service or request was denied and the date it was denied
- The reason you do not agree with the decision
- Any other information that will help in our review
- You must sign the letter
Please keep a copy of the letter for yourself. Send the original letter to:
For Medication Service Appeals:
MDwise Pharmacy Department
PO Box 441423
Indianapolis, IN 46244-0236
OR Fax it to 317-822-7582 or toll-free to 1-844-759-8548
OR Email it to pharmacyappeals@mdwise.org
For Dental Service Appeals:
MDwise Dental Department
Attention: Appeals
PO BOX 44236
Indianapolis, IN 46244-0236
OR Fax it to 866-613-1631
OR Email it to: dentalappeals@mdwise.org
For All Other Service Appeals:
MDwise Customer Service Department
Attention: Appeals
PO BOX 44236
Indianapolis, IN 46244-0236
OR Fax it to 866-613-1631
OR Email it to: padept@mdwise.org
If you or your doctor feel your health could be seriously harmed by waiting 30 calendar days for a decision, you may ask for your Service Appeal to be expedited. If we deny the request for an expedited Service Appeal, we handle it as a standard Service Appeal and send you our decision within 30 calendar days. We will also send you a letter to notify you of the reason we denied the request to expedite your Service Appeal within two (2) days of when you requested the expedited Service Appeal. We will attempt to notify you by telephone as well.
Step 2. Wait for a decision from MDwise.
In an emergency, appeals will be handled quickly. This is called an “expedited” appeal. If your case can be expedited, we will review your case and let you know the decision within 48 hours. Call MDwise customer service to see if this can be done.
The MDwise Appeals Panel will review your issue. MDwise will send you a letter with the date and time the Appeals Panel will meet. You can speak to the panel if you want. You can also have someone else speak for you. This can be done by telephone.
MDwise will send you a letter with an answer to your appeal within 30 days from the time we receive your appeal.
You have the right to review copies of documents that are related to your appeal, this includes records that we used in making our decision such as benefit information, a state rule or guideline. Please call us if you want to review these records. We will provide copies of this information free of charge upon request.
Step 3. Request an external review of the appeal decision.
If you disagree with the appeal decision, you may choose to request either a State Fair Hearing or a review by an Independent Review Organization.
More information about the appeals process and the State Fair Hearing or Independent Review Organization process can be found in your member handbook. You can also call our Customer Service Department at 1-800-356-1204 if you have questions or if you need help filing the appeal.