Medicaid : Florida Healthease Kids Appeals

An appeal is the type of complaint you make when you want us to reconsider and change a decision we have made about:

• What services are covered for your child
• What we will pay for a service

For example, you can file an appeal if…

• We refuse to cover or pay for services you think we should cover.
• We or one of our Plan providers refuses to give your child a service you think should be covered.
• We or one of our Plan providers cuts back on services your child has been receiving.
• You think we are stopping coverage of a service too soon.

A grievance is the type of complaint you make if you have any other kind of problem with the Plan or one of our Plan providers. For example, you would file a grievance if you have a problem with things such as…

• The quality of your child’s care.
• Waiting times for appointments or in the waiting room.
• The way your child’s doctors or others behave.
• Being able to reach someone by phone or get the information you need.
• The condition of the doctor’s office.

Part I. Making complaints (called “appeals”) to Healthease Kids to change a decision about what we will cover for your child or what we will pay for

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

 

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

Problems might be:

 

• Your child is not getting the care you want. You believe that this care is covered by the Plan.
• We will not authorize the medical treatment your child’s doctor or other medical provider wants to give. You believe that this treatment is covered by the Plan.
• You are told that coverage for a treatment or service your child has been getting will be reduced or stopped. You feel that this could harm your child’s health.
• Your child got care that you believe was covered by the Plan while your child was a member. We have refused to pay for this care.

Three possible steps for requesting care or payment from Healthease Kids - There are steps you can take to ask for the care or payment you want from us. Your request is considered at each step. Then a decision is made. There may be another step you can take if you are not happy with the decision.

 

STEP 1: The initial decision by Healthease Kids

First we make an “initial decision” about your child’s care or payment for care. This is also called an “organizational determination.” We will say how we think the benefits we cover apply in your case. You can ask for a “fast appeal.” This is for a decision that needs to be made quickly.

 

STEP 2: Appealing the initial decision by Healthease Kids

You can ask us to rethink our 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 stay with our original decision or change it.

 

How do you file your appeal of the initial decision?

You, someone you appoint or your provider may file this appeal. If you are naming someone to do this for you, you must let us know in writing. Or you can complete an Appointment of Representation form. You can get this form from Customer Service.

 

You may submit your appeal orally or in writing. If you file orally, you must also submit a written, signed appeal request. This is not the case if you are filing a fast appeal.

 

How soon must you file your appeal?

Appeal within 30 days of the date of our notice to you. We may not have sent a notice. Then you have 365 days to appeal.

 

How can your child keep getting benefits while the appeal is being considered?  In order for this to happen:

1. You must file your appeal within 10 days of the date of our notice if you are filing orally. You have 15 days if you are filing in writing by U.S. mail, or before the date of our proposed action takes effect.
2. The appeal must involve stopping or reducing treatment we OK’d previously.
3. The services must have been ordered by an authorized provider.
4. The authorization period cannot have expired.
5. You ask for an extension of benefits.

If you ask for this and your appeal is not decided in your favor, you may have to pay for all costs accrued during the review process.

 

What if you want a “fast” appeal?

You can ask for a fast appeal rather than a standard one. A doctor or representative can also do this for you. This can be done by calling Customer Service. Call Monday through Friday, 8am to 6pm. The toll-free number is 1-866-698-5437.  You can also mail a written report to Healthease Kids, P.O. Box 31368, Tampa, FL 33631-3368. Or fax it to 813-262-2907 or 1-866-201-0657.  Be sure to ask for a “fast” or “expedited” review.

 

We will give you a fast appeal if your doctor says waiting could seriously hurt your child’s health.  You may ask for a fast appeal without your doctor’s help. We will decide if your child’s health requires a fast decision. We will send you a letter if we decide that your child health does not require it. It will say that 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 your child needs a fast review. If we deny your request for a fast review, we will give you a standard review. This usually takes 30 days.

 

How soon must we decide on your appeal?

For a decision about payment for care your child has received: 30 days after we get your appeal.

For a fast decision about care: Up to 72 hours after we get your appeal.

 

If you ask us, or if we find that information is missing that can help you, we can take up to 14 more days to make our decision.

 

STEP 3: Appealing the first-level appeal decision

If you are not happy with the first-level decision, you may appeal. You may do this by asking for a hearing before the Statewide Subscriber Assistance Panel. You may also contact this panel at any time during the process. You must ask for a hearing within 365 days of the Plan’s first-level decision. Do this by contacting the agencies listed below.

PART 2. Making complaints (called “grievances”) to Healthease Kids for issues

We want to know if you have any grievances. Call Customer Service. They will try to fix the issue over the phone. If the issue is not fixed right away, your complaint will be forwarded to the Grievance department.

 

If you have a question about what type of complaint process to use, call Customer Service. Call Monday through Friday, 8am to 6pm. The toll-free number is 1-866-698-5437.

 

As a Healthease Kids member, you have the right to file a grievance about problems such as:

• Quality of services your child received
• Office waiting times
• Doctor behavior
• Facilities
• Involuntary disenrollment
• If you disagree with our decision to take the standard 14 days rather than the 72-hour time frame for appeals

 

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

 

• Bad information
• A lack of information
• A misunderstanding

Grievances must be submitted to the Plan within 365 days. You can do this orally. Or you can do it in writing.  We will send you a letter within 10 days. It will let you know we got your complaint. If your grievance involves medical issues, a doctor will review your case.  The process will be completed within 60 days of when we get your formal grievance. If more information is needed, the 60-day time is stopped. It will start again when we have the information. 

 

We will send you a letter telling you the outcome of the case. It will also tell you that you can ask for a hearing. That hearing would take place before the Statewide Subscriber Assistance Panel. You must ask for this within 365 of our decision.  Other agencies you can contact:

 

The Agency for Health Care Administration
Subscriber Assistance Panel
2727 Mahan Drive
Tallahassee , FL 32308
1-850-921-5458