If HIRSP denies an application or claim payment, the applicant or policyholder will receive directly from HIRSP a written notice of the denial, together with the specific reason for the denial.

An individual may file a grievance regarding their dissatisfaction with HIRSP, including a decision by HIRSP, such as:

1. Denial or termination of coverage.
2. Denial or reduction of payment of a claim.
3. Denial of an application for a subsidy of HIRSP deductible and/or premium.

A policyholder may request a review of the actions listed above according to the following procedures.

Grievance Committee

If the policyholder or applicant disagrees with HIRSP’s decision, the individual may request a review by the Grievance Committee. It is requested that grievances be submitted within 30 days after receiving the plan administrator’s decision. To request the review, the policyholder must submit a written request including pertinent information such as name, identification number, date and place of service, and reason for the review.

Clearly indicate that the written request is for a review.This will help HIRSP process the request.

Mail, fax or email the grievance request to:

HIRSP Grievance Committee
1751 W. Broadway
PO Box 7062
Madison, WI 53707-7062

Fax: (608) 223-3603

Email:  hirspweb@wpsic.com

The policyholder and/or their authorized representative may attend this meeting or teleconference the Committee.  They will have the opportunity to present any additional supporting documentation at this time.  They will receive a seven day advanced notice of the Committee meeting date.

Upon receiving the grievance, the plan administrator will review the decision and either affirm, modify or rescind it.  The plan administrator will communicate this decision, and the reason for the decision, in a written response.  The plan administrator has 30 days from receipt of a grievance to issue a letter of decision or a letter to the requestor asking for more information.  While reviewing the grievance, the committee may need additional time to make its decision.  The committee will send a written notice, by letter, that they need additional time to complete their review of the grievance and make a decision. They will indicate how much additional time they need, when the decision is expected to be made, and the reason additional time is needed.  The committee then has an additional 30 days after the first 30 day period has expired (or 60 days from the date they first received the grievance) to provide the requestor with its written decision.

Expedited Grievance

If we receive an expedited grievance (as defined below), as soon as reasonably possible following our receipt, we will review the expedited grievance.  Our Grievance Department will take the information along with your proposed resolution and review the matter, including considering all information that we have available and this policy’s applicable terms, conditions, and provisions.  As expeditiously as your health condition requires, but not later than 72 hours after our receipt of the expedited grievance, the Grievance Committee will send its written decision by letter, which will contain the specific reasons for its decision.

An expedited grievance is where any of the following applies:

1. The duration of the standard resolution process will result in serious jeopardy to the life or health of the policyholder or the ability of the policyholder to regain maximum function.
2. In the opinion of a physician with knowledge of the policyholder’s medical condition, the policyholder is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance.
3. A physician with knowledge of the policyholder’s medical condition determines that the grievance shall be treated as an expedited grievance.

Mail, fax or email the expedited grievance request to:

HIRSP Grievance Committee
Expedited Grievance
1751 West Broadway
PO Box 7062
Madison, WI 53707-7062

Phone:  (608) 221-7128 or toll-free 1-800-828-4777, extension 17128

Fax: (608) 223-3603

Email:  hirspweb@wpsic.com

Appeals Committee

If the policyholder or applicant disagrees with the Grievance Committee’s decision on the review, the individual may file an appeal. We request that appeals be submitted within 30 days after receiving the grievance decision letter.  To file an appeal, the individual must submit a written request including pertinent information such as name, identification number, date and place of service, and reason for the appeal.

Clearly indicate that the written request is an appeal. This will help the Appeals Committee process the request.

Mail, fax or email the appeal to:

HIRSP Authority
Attn: Appeals Committee
33 East Main St., Suite 230
Madison, WI 53703-5105

Fax: (608) 441-5776

Email:  info@hirsp.org

Upon receiving the request, the Appeals Committee will review the decision and either affirm, modify, or rescind it. The Appeals Committee will communicate this decision, and the reason for the decision, in a written response within 45 days from the receipt of the request for review.