Appeals and Grievances
Please Let Us Know Right Away About Problems With Your Child's Health Care.
Call Customer Service with any questions you may have Monday through Friday, 7 a.m. to 7 ;.m. The toll-free number is 1-866-698-5437 (TTY 711).
This section gives the rules for making complaints. State law says you have the right to make complaints about any part of your child’s medical care as a plan member. The state has helped set the rules about what you need to do to make a complaint. There are also rules about what we must do when we get a complaint. We must be fair in how we handle it. We cannot disenroll your child from our plan or treat you differently. You will not be penalized in any way.
You have the right to make a complaint about your child’s coverage or care.
There are two types of complaints. They are called:
What is an Appeal?
An appeal is a request you can make when you do not agree with a decision we made about your child’s care. Or it can be for if we take too long to make a care decision. You can ask for an appeal if we:
- Deny or limit a service you or your doctor asks us to approve
- Reduce, suspend or stop services your child has been getting that we already approved
- Do not pay for the health care services your child gets
- Fail to give services in the required timeframe
- Fail to give you a decision on an appeal you already filed in the required time frame
You will get a letter from us when any of these actions occur. It is called a "Notice of Adverse Benefit Determination" or "NABD".
You can file an appeal if you do not agree with our decision.
You may file an oral appeal or in writing within 60 calendar days from the date on the Notice of Adverse Benefit Determination. Call 1-866-698-5437 (TTY 711) Monday - Friday, 7 a.m. to 7 p.m. If you call in your appeal, you must follow up with one that's written and signed. Make sure to do this within 10 calendar days of your call.
Send your written requests here.
For appeal requests for medical services:
Tampa, FL 33631-3368
Fax to: 1-866-201-0657
For appeal requests for pharmacy medications:
Fax to: 1-888-865-6531
You can file your appeal yourself. Or you can have someone file it for you. (This includes your child’s PCP or another provider you choose.) We must have your written consent before someone can file an appeal for you. We can also help you with your appeal.
We will send you a letter within five business days of getting your appeal. It will let you know we got your appeal. After we review the appeal, we will send you a Notice of Plan Appeal Resolution letter within 30 calendar days. You or the person acting on your behalf can review the information we used to make our decision.
Fast or "Expedited" Appeals
There may be times when you or your provider will want us to make a faster appeal decision. This could be because you or your provider feels that waiting 30 calendar days could seriously harm your child’s health. If so, you can ask for an expedited or "fast" appeal.
You or your provider must call or fax us to ask for a fast appeal. Our fax number is 1-866-201-0657 (for a medical appeal) or 1-888-865-6531 (for a pharmacy appeal). If your appeal is made verbally, we do not need it in writing.
If we decide you need a fast appeal, we will call you with our decision. We will do this within 72 hours after receiving and accepting your fast appeal. We will also send you a letter with our decision. If you ask for a fast appeal and we decide that one is not needed, we will:
- Change the appeal to the time frame for a standard decision (30 calendar days)
- Call you the same day we decide a fast appeal is not needed to tell you about our denial of your fast appeal request
- Follow up with a written letter within two calendar days
- Tell you over the phone and in writing that you may file a grievance about the denial of your fast appeal request
You or someone acting for you can give us more information if you feel it will help your appeal. You can do this at any time during the appeal process.
For a standard appeal, you can ask us for up to 14 more calendar days to give us more information. If needed, we may ask for 14 more calendar days to decide on a standard appeal. If we need more time, we will call you to tell you more time is needed. We will also send you a letter to tell you why, within two calendar days. We will do this if we need more information and it is in your best interest.
What if I am not satisfied with the results of my appeal?
You may ask for an external review if you are not happy with the appeal decision. You may do this by asking for an external review by contacting the Health Plan.
For external review request for medical services:
Fax to: 1-888-865-6531
- You must complete our appeal process before you can ask for an external review
- You must ask for an external review within 4 months (120 days) of our decision
What is a Grievance?
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
Making Complaints Called "Grievances"
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, 7 a.m. to 7 p.m. The toll-free number is 1-866-698-5437 (TTY 711).
As a Staywell 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
- Involuntary disenrollment
- If you disagree with our decision to take the standard 30 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 can be submitted to the plan at anytime. You can do this orally or in writing. Send your written grievance to:
Fax to: 1-866-388-1769
We will send you a letter within 5 business days. It will let you know we got your complaint. A doctor will review your child's case if your grievance involves medical issues.
- The process will be completed within 90 days of when we get your formal grievance.
- The 90-day time is stopped if more information is needed from outside the service area. It will start again when we have the information.
- Up to 14 calendar days can be added to the process. We will let you know if this happens. You may also ask for extra time.