In the event that Community Care makes only a partial payment or denies payment of a Clean Claim, you have the right to an appeal. Appeals must be submitted in writing within 60 calendar days of the initial denial or partial payment. Non-contracted providers must include a signed Waiver of Liability Form which holds the enrollee harmless regardless of the outcome of the appeal. Appeal must be clearly marked “APPEAL,” and contain the provider name, date of service, date of billing, date of rejection and reason(s) claim should be reconsidered. Community Care must respond in writing within 45 calendar days of the receipt of the request for reconsideration.

If Community Care fails to respond to  the appeal within 45 days or if you are not satisfied with Community Care's response with your original appeal you also have the right to appeal to the Wisconsin Department of Health and Services (DHS) regarding the payment or non-payment of services.  DHS will not consider your appeal if you do not first submit it to Community Care. You must submit appeals to DHS in writing within 60 days of Community Care’s final decision, or in the case of no response, within 60 days from the end of the 45-day timeline allotted to Community Care. If appropriate, submit your DHS appeal to:

Fax:      (608) 266 - 5629
Or
Mail: Provider Appeals Investigator
Division of Medicaid Services
1 West Wilson Street, Room 518
P.O. Box 309
Madison, WI 53701-0309