Medicaid Grievances & Appeals in West Virginia

Let us know if we’ve missed the mark

If you ever feel like you weren’t cared for or respected, please let us know. This could include an experience with a Wellpoint representative, one of your healthcare providers, or an in-network specialist. You can also file an appeal if you disagree with an initial decision we made concerning your care. Your feedback helps us better provide quality care and the services you deserve.

Grievances

Filing a grievance helps us to quickly solve your issue and ensure you’re treated fairly. You may want to file a grievance if:

You're not happy with Wellpoint for any reason.
You've had a problem with the quality of care you’ve received from our services or network providers.
You've had trouble getting care.
You feel your rights have been disrespected.
You were subject to rude behavior from a provider or someone from Wellpoint.

How to file a grievance

You can file a grievance letter or send us a Member Grievance Form any time by:

Calling the Customer Care Center at 800-782-0095 (TTY 711).
Faxing your grievance letter to 844-882-3250.
Mailing your letter to:

Grievance and Appeals Department

Wellpoint West Virginia, Inc.

P.O. Box 91

Charleston, WV 25321-0091

You can also have a representative help you file your grievance. This can be a family member, friend, healthcare provider, or lawyer. Make sure you provide the date your grievance happened, who was involved, and as much information about the event as you can.

Grievance resources

Member Grievance Form (English)

What happens after you submit your grievance?

Wellpoint will send an acknowledgement letter within five calendar days of receiving your grievance. From this date, we will review the issue and send our decision within 30 calendar days of receiving your complaint. You will receive our decision in writing.

You can appeal if you disagree with our decision

An appeal is a formal way of asking us to review and change a coverage decision we made. The appeal can be made by a phone call or in writing.

If we deny, reduce, or end treatment or services, we’ll send you a Notice of Action. It will:

Explain why we won't pay for the care or services your provider asked for.
Tell you about your right to appeal our decision.

You or your approved representative can appeal the decision. If you have an approved representative file the appeal on your behalf, you must send us the Appeal Representative Form.

How do you file an appeal?

You can file an appeal within 60 calendar days from the date you receive your Notice of Action. You or your representative can file by:

Calling Wellpoint at 800-782-0095 (TTY 711).
Faxing your appeal to 844-882-3520.
Mailing your grievance letter, Member Appeal. Request Form, or Member Appeal Representative Form to:

Attn: Grievance & Appeals Department

Wellpoint West Virginia, Inc.

P.O. Box 91

Charleston, WV 25321-0091

Appeal process resources

Member Appeal Request Form (English)

Appeal Representative Form (English)

Keep getting your requested services during the appeal

You or your representative can also ask for your denied or reduced service to continue during the appeal decision process. To do this, you must request your service within 10 calendar days from the change of service date on the Notice of Action. You can send this request by calling Customer Care Center at 800-782-0095 (TTY 711) or mailing your request to:

Attn: Grievance & Appeals Department

Wellpoint West Virginia, Inc.

P.O. Box 91

Charleston, WV 25321-0091

If we agree with your appeal, we will pay for the services you receive during this time. If we deny your appeal, you may need to pay for your services while waiting for an appeal decision.

An acknowledgement letter will be mailed to you within five calendar days of receiving your appeal request. We’ll then review your appeal and send you a decision letter within 30 calendar days.

Wellpoint may ask for 14 more calendar days if we don’t have enough information about your appeal. You’ll receive a letter within two calendar days telling you why we need more time to process your appeal.

You can also ask for 14 more calendar days if you or your representative have more information to send. You can send your additional info by:

Calling 800-782-0095 (TTY 711).
Faxing your additional information to 844-882-3520.
Mailing in or dropping off your info in-person to:

200 Association Drive

Ste. 200

Charleston, WV 25311

If the standard 30-day appeal decision would put your or your child’s health at risk, please ask for an expedited appeal.

We will send you a letter acknowledging your expedited appeal request within 24 hours of receiving it. You will then be notified of our appeal decision within 72 hours (three days) after we receive your appeal.

If your appeal is denied, you’ll receive a decision letter explaining our reasoning about denying your expedited appeal request within five calendar days.

If your appeal request was denied, you have the right to ask for a Fair Hearing from West Virginia. A Fair Hearing is an opportunity to share more relevant information and ask an administrative law judge about the first appeal decision. The judge in your Fair Hearing is not associated with Wellpoint in any way. Appeals for non-covered services are not eligible for State Fair Hearings, unless requested under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits.

You can ask for a Fair Hearing anytime up to 120 calendar days after receiving the written appeal decision. You can send your request for a Fair Hearing to the:

WV Bureau for Medical Services

Office of Medicaid Managed Care

350 Capitol St., Room 251

Charleston, WV 25301-3708

If a State Fair Hearing is requested, the state of West Virginia will take your case and send you a written decision within 90 days of the date you requested a State Fair Hearing.

Mediation is an informal voluntary process to see if everyone can come to an agreement on your case. You do not have to ask for mediation to receive a Fair Hearing. Mediation is guided by a third-party, professional mediator. If we do not reach an agreement with you, you can still have a Fair Hearing. You can also decide not to go through mediation and only request for a Fair Hearing.

If you need help with understanding the Fair Hearing or mediation processes, you can contact our Community Outreach Specialists at 888-611-9958.

You can take your case to Circuit Court. The first step to doing this is filing your notice within 30 days of receiving your State Fair Hearing decision. You can file your appeal to the Bureau for Medical Services (BMS) at:

WV Bureau for Medical Services

Office of Medicaid Managed Care

350 Capitol St., Room 251

Charleston, WV 25301-3708

The BMS will send you a letter with their decision. If you are unhappy with the BMS’s decision, you can then appeal to the West Virginia Insurance Commissioner by mailing your appeal to:

The Office of the Insurance Commissioner

P.O. Box 50540

Charleston, WV 25305-0540