Family Care, Partnership, and PACE Member Information - Filing an Appeal with Your MCO

If you received a notice of action for a termination, denial, or reduction of services and you disagree with this decision you can appeal. You have the right to appeal to your Managed Care Organization's (MCO) Grievance and Appeals Committee. You can appear in person, if you choose. You can bring an advocate, friend, family member, or witness. You may also present evidence to this committee.

It is your right to file an appeal but you could also contact your care manager or the member rights specialist to informally resolve the concern. Informal resolution is typically quicker and more beneficial for you.

To file an appeal with the MCO's Grievance and Appeals Committee, contact your care manager or the member rights specialist. You can also start the process by submitting a request form. Please select the request form for your MCO.  

Managed Care Organization (MCO) Link to Form
Care Wisconsin Form F-00237 CW (Word)
Community Care, Inc. Form F-00237 CCI (Word)
Form F-00237S CCI, Spanish (Word)
Inclusa, Inc. (formerly Community Link, Inc.) Form F-200237 Inclusa (Word)
Independent Care Health Plan (iCare) Form F-00237 iCare (Word)
Lakeland Care, Inc. Form F-00237 LCI (Word)
My Choice Family Care Form F-00237 My Choice (Word)

Note: The forms are MS Word fillable. Microsoft Word-fillable forms, can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Last Revised: September 22, 2017