DHS 10.53(2)(b) (b) The department shall review and approve a CMO’s grievance and appeal process as part of its contracting with the CMO.

DHS 10.53(2)(bg) (bg) An enrollee may file a grievance at any time.

DHS 10.53(2)(br) (br) The CMO shall complete its review of a grievance and issue its written decision to the enrollee within 90 days of its receipt of the grievance, unless the grievance decision timeframe is extended under the extension requirements specified in the contract with the department.

DHS 10.53(2)(c) (c) The CMO shall inform enrollees of all of the following:

DHS 10.53(2)(c)1. 1. The circumstances under which expedited resolution of a grievance is available and how to request it.

DHS 10.53(2)(c)2. 2. The enrollee has the right to appear in person before the CMO personnel assigned to resolve a grievance, if the enrollee files the grievance.

DHS 10.53(2)(c)3. 3. The availability of independent advocacy services and other local organizations that might assist an enrollee with a grievance.

DHS 10.53(2)(c)4. 4. The enrollee may obtain, free of charge, copies of enrollee records relevant to the grievance and how to obtain the copies.

DHS 10.53(2)(d) (d) A CMO shall assist enrollees with filing grievances with the CMO. If an enrollee is dissatisfied with the CMO’s grievance decision, or the CMO fails to render a grievance decision within the timeframe specified under par. (br), a CMO shall assist the individual with requesting a department review of the grievance under s. DHS 10.54.

DHS 10.53(2)(dm) (dm) An enrollee must request department review within 45 days of the date on the grievance decision.

DHS 10.53(2)(e) (e) The CMO shall complete its review of an appeal and issue its written decision to the enrollee within 30 days of its receipt of the appeal, unless the appeal decision timeframe is extended under the extension requirements specified in the contract with the department.

DHS 10.53(2)(f) (f) A CMO shall assist enrollees with filing appeals with the CMO. If the enrollee is dissatisfied with the CMO’s appeal decision, or the CMO fails to render an appeal decision within the timeframe specified under sub. (2) (e), a CMO shall assist the individual with requesting a fair hearing with the division of hearings and appeals under s. DHS 10.55.

DHS 10.53 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (a) to (c) and (2) (a) to (c) Register November 2004 No. 587, eff. 12-1-04; CR 22-026: am. (title), (1) (a), (b), renum. (1) (c) to (1) (c) (intro.) and am., cr. (1) (c) 1. to 4., (d) to (f), (1m), am. (2) (title), (a), (b), cr. (2) (bg), (br), r. and recr. (2) (c), cr. (2) (d) to (f) Register May 2023 No. 809, eff. 6-1-23; correction in (2) (d), (f) made under s. 35.17, Stats.,correction in numbering of (2) (dm) made under s. 13.92 (4) (b) 1., Stats., and correction in (2) (f) made under s. 13.92 (4) (b) 7., Stats., Register May 2023 No. 809.

DHS 10.54 DHS 10.54 Department reviews.

DHS 10.54(1) (1) Department review process for grievances filed with a resource center. The department shall review, investigate, and analyze the facts surrounding client grievances in an attempt to resolve concerns and problems informally, whenever either of the following occurs:

DHS 10.54(1)(a) (a) A client makes a grievance directly to the department.

DHS 10.54(1)(b) (b) A client requests department review of a decision arrived at through a county agency or resource center grievance process.

DHS 10.54(2) (2) Timeliness of review. The department shall complete its review under sub. (1) within 20 days of receiving a request for review from a client, unless the client and the department agree to an extension for a specified period of time.

DHS 10.54(2e) (2e) Department review process for grievances filed with a CMO. The department shall review and resolve enrollee grievances whenever either of the following occurs:

DHS 10.54(2e)(a) (a) An enrollee requests department review of a decision arrived at through a care management organization grievance process under s. DHS 10.53 (2).

DHS 10.54(2e)(b) (b) An enrollee requests department review of a grievance request that the CMO has failed to act on within the timeframe specified under s. DHS 10.53 (2) (d).

DHS 10.54(2j) (2j) Timeframe for requesting department review. An enrollee must file the request for grievance review within 45 days of the receipt of the CMO’s written decision regarding the enrollee’s grievance or, if the CMO fails to issue a written grievance decision to the enrollee within the timeframe specified under s. DHS 10.53 (2) (d), within 45 days of the date that timeframe expires.

DHS 10.54(2o) (2o) Timeliness of review. The department shall complete its review under sub. (2e) within 30 days of receiving a request for review from an enrollee, unless the enrollee and the department agree to an extension for a specified period of time.

DHS 10.54(2v) (2v) Timeliness of decision. The department shall mail or hand deliver to the enrollee and the CMO a written decision resolving the grievance within 7 days of the completion of the grievance review. This decision is final and binding on both the enrollee and CMO. Department review is the final process in resolving enrollee grievances.

DHS 10.54(3) (3) Department review process for fair hearings. Whenever the department receives notice from the department of administration’s division of hearings and appeals that it has received a fair hearing request under s. DHS 10.55 (3), the department shall conduct an informal review in accordance with s. DHS 10.55 (4).

DHS 10.54 History History: Cr. Register, October, 2000, No. 538, eff. 11-1-00; CR 04-040: am. (1) (intro.) (a) and (3) Register November 2004 No. 587, eff. 12-1-04; CR 22-026: am. (1), (2) (title), cr. (2e) to (2v), am. (3) Register May 2023 No. 809, eff. 6-1-23.

DHS 10.55 DHS 10.55 Fair hearing.

DHS 10.55(1) (1) Right to fair hearing in resource center and county agency adverse benefit determinations. Except as limited in sub. (3) and s. DHS 10.62 (4), a client may contest any of the following adverse benefit determinations by filing, within 45 days of receipt of notice of the adverse benefit determination, a written request for a hearing to the division of hearings and appeals:

DHS 10.55(1)(a) (a) Denial of eligibility under s. DHS 10.31 (6) or 10.32 (4).