All health plans and insurance vendors, such as dental and vision, are required to make a reasonable effort to resolve your problems and complaints. If you are unsatisfied with the administration of a covered service, review the steps below.

Step 1: Contact the Plan or Vendor for Resolution

If you have an insurance issue, contact the plan or vendor to try to resolve the process informally. Many issues are resolved with a few calls to the plan or your provider.

If you have a Wisconsin Retirement System retirement benefit or disability benefit issue, contact ETF.

Step 2: File a Grievance with the Plan or Vendor

If the problem cannot be resolved informally, you may file a grievance or an appeal with the plan or insurance vendor. The terms “grievance” and “appeal” are often used interchangeably by health plans and insurance vendors. A grievance/appeal is an expression of dissatisfaction with a plan’s performance, claims processing, prior authorization criteria, and enrollment rules. Throughout this section, we’ll use the term grievance.

To file a grievance:

  1. Contact the plan or vendor for information on how to file a grievance and to request the plan’s grievance policy.
  2. Review the grievance policy.
  3. Determine which Certificate of Coverage policy or provision you disagree with.
  4. Gather relevant information, documents, and medical records. Document what you believe would be a resolution of your case.
  5. Submit grievance materials to your plan. Your grievance should be acknowledged within 7-10 days.
  6. Participate in the grievance meeting, by phone or in person. Prepare questions and statements ahead of time to present in the meeting.
  7. Await grievance committee outcome

You may contact an ETF Ombudsperson before or after going through the plan grievance process. In either case, the ombudsperson can assist as a "navigator" by providing guidance, options, and resources.

Step 3: Contact Ombudsperson Services

If your issue remains unresolved and you are dissatisfied with the outcome of the plan or vendor’s review, contact Ombudsperson Services. An ombudsperson can help you determine if you are eligible for either an Independent External Review or an ETF Administrative Review.

Ombudsperson Services

An ombudsperson acts as a neutral party while helping with your benefit concerns. The goal is to offer a fair resolution for all parties while adhering to program policies, contracts, and the law.

An ETF Ombudsperson Can Help:

  • When a prior authorization request has been denied
  • When claims have not been processed correctly
  • When you have been told you have no insurance coverage
  • If you want to file a grievance or an independent review
  • If you receive a bill for services that were covered in the past
  • When you have enrollment or eligibility issues

An ETF Ombudsperson Cannot:

  • Guarantee a favorable outcome
  • Change any plan’s policy
  • Authorize claims payment
  • Make medical determinations
  • Make ETF policy or management decisions

Contact Ombudsperson Services

Contact ETF’s Ombudsperson Services via email or phone at 608-261-7947.