Medicaid : Florida Healthease Appeals

 

File an appeal when you want us to change a decision about what we will cover or pay for. Let’s say we will not cover or pay for services you think we should cover.  Then you would file an appeal.  You can appeal if the plan or a provider will not give you a service you feel should be covered.  You can appeal if the plan or a provider cuts back services you have been getting.  You can also appeal when you feel we are stopping services too soon.

A grievance is a different type of complaint.  It is about something other than a coverage decision.  File a grievance for issues such as:

 

• Not being able to get information
• The condition of your doctor’s office
• The quality of your care
• The way your doctors or others behave
• Waiting times

 

MAKING AN APPEAL

This section tells you what to do about problems getting health care you think we should provide.  We use the word “provide” to include such things as:

 

• Arranging for someone to give you care
• Authorizing care or prescriptions
• Continuing to provide a treatment you have been getting
• Paying for care

 

Problems might include:

 

• You are not getting the care you want. You feel that this care is covered by Healthease.
• We will not authorize the medical treatment your doctor wants to give you. You believe that this treatment is covered by the plan.
• You are told that coverage for a treatment you get will be reduced or stopped. You feel that this could harm your health.
• You got care that you believe was covered by Healthease. We have refused to pay.

 

Steps for Asking for Care or Payment from Healthease

There are steps you can take to ask for care or payment for care when you have a problem getting them.  Your request is considered at each step. Then a decision is made.  There may be another step to take if you are not happy with the decision.

 

Step 1 - The Initial Decision by Healthease

 

First, we make an “initial decision” about care or payment for care.  This is also called a “service authorization decision” or “action.”  We will say how we feel the benefits we cover apply in your case.  You can ask for a “fast initial decision.”  This is for a decision that needs to be made quickly.  You or someone you appoint can see your case file.   This can include medical records.  It may also have other related items.  You can ask for the written guidelines we used to make the decision.  You can also ask to see a summary of our written policies and procedures about appeals.

 

Step 2 - Appealing the Initial Decision by Healthease

 

You can ask us to review our initial decision.  This is called an “appeal” or a “request for reconsideration.” You can ask for a “fast appeal.”  This is for health care requests that need quick decisions. We will review your appeal. Then we will decide to keep our initial decision or change it.

 

How do you file your appeal of the initial decision?

 

You, someone you appoint or you doctor may file this appeal.  First, you must give them written consent.  You must let us know someone else is doing this for you.  You can do this by writing us a letter.  Or you can fill out an Appointment of Representation form.  You can get this from Customer Service.   A representative may file for the estate of a member who has died.  He or she must have proper documents.

 

You may file a verbal or written appeal.  A verbal appeal must come with a written appeal request that is signed. (This is not needed with a fast appeal.)  A verbal appeal can be filed by calling Customer Service.  A written appeal should be mailed to:

 

Healthease Health Plan
Attn: Appeals Department
P.O. Box 31368
Tampa , FL 33631-3368

 

A written appeal can also be faxed. Fax it to 1-866-201-0657.

What if I want to appeal a decision made about a prescription?   Do I do anything different?

 

You can still call Customer Service.  But written appeals go to a different address.  Send your appeal to:

 

Healthease Health Plan
Attn: Pharmacy Appeals Department
P.O. Box 31398
Tampa , FL 33631-3398

You can fax it too. Fax it to 1-888-865-6531.

 

We will send you a letter within 10 calendar days after we get your appeal. It will let you know we got your appeal. We will not send one if it is a request for a fast appeal. You will get a decision letter if we are able to resolve the appeal within 10 calendar days.

How soon must I file my appeal?

 

Appeal within 30 calendar days of the date of our notice to you.

 

How do I keep getting benefits while waiting for an appeal decision? What other rights do I have? 

 

See the Medicaid Fair Hearing section.

 

What if I want a fast or expedited appeal?

 

You can ask for a fast appeal instead of a standard one.  A doctor or representative can do this for you.  Call Customer Service for help.  Or you can send an appeal to:

 

Healthease
P.O. Box 31368
Tampa , FL 33631-3368

You can also fax it to 1-866-201-0657.   Be sure to ask for a fast review. 

 

Send an appeal for a decision we made on prescription to:

 

Healthease Health Plan
Attn: Pharmacy Appeals Department
P.O. Box 31398
Tampa , FL 33631-3398

 

You can fax it too.  Fax an appeal for a prescription to 1-888-865-6531.  Don’t forget to ask for a fast review.

 

We will give you a fast appeal if your doctor says waiting could seriously harm your health.  You may ask for a fast appeal without a doctor’s help. We will decide if you need a fast decision. We will try to call you if we decide your health does not require it. We will also send you a letter within 2 days. It will say you can get a fast review with a doctor’s support. The letter will also tell you how to file a grievance if you disagree and feel you need a fast review. We will give you a standard review if you decide not to do a fast review. This usually takes 30 calendar days.

 

How soon must we decide on your appeal?

 

For a decision about payment for care you have received:

 

• 30 calendar days after we get your appeal
• For a standard decision about your medical care or a prescription:
  •  30 calendar days after we get your appeal. We will make it sooner if your health requires.
  • You can get 14 more days if you ask or if we find information that will help you. You can ask for this extra time by writing to us or calling Customer Service. We will send you a letter if we take extra time.  The letter will say why.  We will also let you know the date we expect to make a decision. 

 

For a fast decision about medical care or a prescription:

 

 

• Up to 72 hours after we get your appeal. 
• Sooner if your health requires it. 

 

You can get 14 more days if you ask or if we find information that will help you.  You can ask for this extra time by writing to us or calling Customer Service. We will send you a letter if we take extra time.  The letter will say why. We will also let you know the date we expect to make a decision.   We will mail you a letter in each case.  It will tell you about your appeal rights if the decision is not in your favor. We will also try to call you about standard decisions.

 

How can I present evidence and/or allegations of fact or law?

 

You may do this in your written request or in person. To do this in person, please contact Customer Service. Tell them of your request.  Someone will contact you to set up a time.

 

Can I review my case file?

 

You or someone you appoint may see the case file. You can see it before and during the appeal process. It can include medical records and other documents. Just call Customer Service if you want to see your case file.

 

Step 3 - Appealing to the Subscriber Assistance Program (SAP)

 

You can file with the SAP.  You can do this if you are not happy with our first decision.  You can contact the SAP at any time during the process.   You must ask for a hearing within one year.  The SAP will only hear your case if it involves:

 

• Availability of health care services
• Benefit action or denial made by us
• Coverage of benefits
• How we handle or pay claims

 

You can contact the SAP at:

 

Agency for Health Care Administration
Subscriber Assistance Program
Building 1, MS #26
2727 Mahan Drive
Tallahassee , FL 32308
1-850-921-5458 | (toll-free) 1-888-419-3456

 

You may not request a SAP review if you also ask for a Medicaid Fair Hearing.

 

MEDICAID FAIR HEARING

You can ask for a Medicaid Fair Hearing. Just contact the Department of Children and Family Services at:

 

Office of Public Assistance Appeals Hearings
1317 Winewood Boulevard
Building 5, Room 203
Tallahassee , FL 32399-0700
1-850-488-1429

 

There is a deadline to ask for this.  It must be within 90 days of the notice of action or initial decision.  Please note—you can’t have a SAP review and a Medicaid Fair Hearing.

 

How can I keep my benefits during the Medicaid Fair Hearing process?

 

In order for this to occur:

 

• The appeal must involve the end, stopping or reduction of treatment that had been previously approved
• The authorization period cannot have expired
• The services must have been ordered by an authorized provider
• You must file your appeal within 10 calendar days of the date of the notice of action if filing verbally; or if filing in writing and submitting via US mail, within 15 calendar days, or prior to the intended effective date of our proposed action

 

You must request an extension of benefits If we continue your benefits during the hearing process, the benefits will continue until one of the following occurs:

 

• 10 calendar days pass from an verbal request or 15 calendar days pass from a written (mailed) request from the date of the plan’s adverse decision; and you have not requested a “Medicaid Fair Hearing with continuation of benefits until a Medicaid Fair Hearing decision is reached”
• A Medicaid Fair Hearing decision is made that is not in your favor
• The authorization expires or the authorized service limits are met
• You withdraw the appeal. You may have to pay for all costs that collect during the review if you lose the hearing. The plan may recover the cost of the services given to you during this process.

 

What happens if the Medicaid Fair Hearing rules in my favor?

 

We will approve and pay for services as quickly as possible.  The plan will pay for services that were in dispute. We will do this:

• According to state policy and rules
• If the services were given while the hearing was ongoing
• If the final decision reverses our decision

 

FILING A GRIEVANCE

 

We want to know if you have any grievances.  They must be submitted within one year after the issue occurred.  Call Customer Service. We will try to fix the issue over the phone.  You may also write to us.  Mail your grievance to:

 

Healthease Health Plan
Attn: Grievance Department
P.O. Box 31384
Tampa , FL 33631-3384

It can also be faxed to us. Fax it to 1-866-388-1769.

 

As a Healthease member, you can file a grievance about problems such as:

 

• Doctor behavior
• Facilities
• If you feel we should process your request for an appeal in the expedited 72 hours rather than the standard 30 calendar days
• If you feel we should process your request for a service in the expedited 72 hours rather than the standard 14 calendar days
• Involuntary disenrollment
• Office waiting times
• Quality of services

 

We will try to fix any problem you might have.  We can solve many issues over the phone. These may be about:

 

• A lack of information
• A misunderstanding
• Bad information

 

You have rights outside the plan’s process.  They are included in the Medicaid Fair Hearing section of this handbook.  Grievances that are not settled right away will go to a Customer Service Grievance Coordinator (CSGC). We will send you a letter within 10 days. It will let you know we got your complaint. Or you will get a decision letter if the issue is settled.

 

A doctor will look at cases that involve medical issues. Once we get your grievance, the process will take 30 calendar days or less. It may take longer if more details must be gathered. 

 

Up to 14 calendar days can be added to the process if we need more information. We will let you know if this happens. You may also ask for extra time. To do so, ask your case representative. We will send you a letter if we need extra time. The letter will let you know when we expect to make a decision. It will also tell you what to do if you do not agree with the extra time.

 

We will send you a letter telling you the outcome of the case. It will also tell you that you can ask for a second-level grievance. You do not have to do this. If you do ask for one, you must send your request in writing. You must do this within 30 calendar days after you get our decision. Send it to the Grievance Committee (GC). You will have less time to file an appeal to the state if you file a second-level grievance.

 

You may also present your case to the GC in person or by phone. To do this, please include this in your request. Our GC meets every Thursday from 9am to 10am Eastern. We will contact you to set up a meeting date.  You will have 10 minutes to present your side of the case to the GC. GC members may then ask questions. You will be sent a decision letter within five business days of the GC meeting.  The second-level process takes 30 calendar days or less in most cases.

 

What happens if you do not agree with the second-level findings? You can ask the Subscriber Assistance Program (SAP) to hear your case. You must finish the plan’s grievance process before they will hear your case. Be sure to ask for a hearing within one year after the event in question occurred.

 

In order for the SAP to hear your grievance, the following must be met:

 

• Your grievance was filed in writing
• You submitted your request within one year of when the issue you are grieving about occurred
• Your issue concerns the quality of health care services you have received or your issue involves the contractual relationship between you and us

 

EXHAUSTION OF GRIEVANCE PROCEDURES

 

You must finish the appeals and grievances steps before taking legal action.  Call the Consumer Call Center at 1-888-419-3456 . It is there to help people with Medicaid. They can answer questions about quality of medical care.

 

Additional Help With Appeals And Grievances

 

Here are some other agencies you can contact during or after the appeals or grievance process:

Agency for Health Care Administration
Subscriber Assistance Program
Building 1, MS #26
2727 Mahan Drive
Tallahassee , FL 32308
1-850-921-5458 | (toll-free) 1-888-419-3456

 

Department of Financial Services
Consumer Affairs
200 East Gaines Street
Tallahassee , FL 32399
1-800-342-2762

 

We keep track of all appeals and grievances.  We report this information to the state.  This also helps us give members better service.

Last modified: 05/27/2010