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Appeals and Grievances

We want you to let us know right away if you have any questions, complaints or problems with your covered services or the care you receive.

This section explains how you can tell us about these concerns/complaints.

There are three kinds of complaints you can make. They are called:

State law allows you to make a complaint if you have any problems with us. The State has also helped to set the rules for making a complaint. As well as what we must do when we get a complaint. If you file a grievance or an appeal, we must be fair. We cannot disenroll you from our plan or treat you differently.

What is an Appeal?

An appeal is a request you can make when you do not agree with a decision we made about your 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 you've been getting that we already approved
  • Do not pay for the health care services you get
  • Fail to give services in the required time frame
  • Fail to give you a decision on an appeal you already filed in the required time frame
  • Do not agree to let you see a doctor who is not in our network and you live in a rural area or in an area with limited doctors

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 1-866-334-7927 (TTY 711) Monday-Friday, 8 a.m. to 7 p.m. If you call in your appeal for a standard request, 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: 

Staywell Health Plan
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368
Fax to: 1-866-201-0657 

For appeal requests for pharmacy medications: 

Staywell Health Plan
Attn: Pharmacy Appeals Department
Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398
Fax to: 1-888-865-6531 

You can file your appeal yourself. Or you can have someone file it for you. (This includes your 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 free of charge. 

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 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 

Additional Information 
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. You may also review a copy of your appeal at any time during or after 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. 

Additional Appeals Assistance 
If you are not happy with our appeal decision, you can ask for a Medicaid Fair Hearing. Please note that MediKids members do not have the right to file a Medicaid Fair Hearing. MediKids members can ask for a State Review.

Medicaid Fair Hearing 

Here are some things you should know about a Medicaid Fair Hearing (MFH).

When Can You Ask for One?
You may ask for a Fair Hearing any time up to 120 days after getting our decision on your appeal. This is called a Notice of Plan Appeal Resolution (NPAR). 

MediKids State Review

You can ask for a State Review. Here are some things you should know about a State Review.

When can you ask for one? You may ask for a State Review after you complete the internal appeal process.

You can request a State Review within 30 calendar days of getting our decision on your appeal. This is called a “Notice of Plan Appeal Resolution (NPAR).”

To request a Medicaid Fair Hearing or State Review, write to:

Agency for Health Care Administration
Medicaid Hearing Unit
P.O. Box 60127

Ft. Myers, FL 33906

 

You can also:

Your written request for a Medicaid fair hearing or State Review must include the following information:

  • Your name
  • Your member number
  • Your Medicaid ID number (Not applicable to MediKids members)
  • A phone number where we can reach you or your authorized representative 

You may also include the following information if you have it:

  • Why you think we should change the decision
  • Any medical information to support the request
  • Who you would like to help with your fair hearing 

After getting your fair hearing or State Review request, the Agency for Health Care Administration (Agency) will tell you in writing that they got your request.

Remember:

Medicaid Fair Hearing:

  • You must complete the internal appeal process.
  • You must request within 120 calendar days of receipt of our Notice of Plan Appeal Resolution.
  • This process does not apply to MediKids members.

MediKids State Review:

  • You must complete the internal appeal process.
  • You must request within 30 calendar days of receipt of our Notice of Plan Appeal Resolution.

Continuation of Benefits During the Appeals Process (Not Applicable to MediKids Members)

You can ask that we continue to cover your medical services during the appeals process. To do this: 
  • You must file your appeal with us within 10 calendar days of our mailing the Notice of Adverse Benefit Determination (NABD) to you or on or before the first day that the service will be reduced, suspended or stopped, whichever is later
  • Your appeal involves an action we're taking to reduce, suspend or stop a service we had already approved
  • The service must have been ordered by an authorized provider
  • The original time period covered by the approval we gave has not yet ended
  • You need to ask for a continuation of benefits

We will continue your benefits until one of the following happens:

  1. You withdraw your appeal
  2. 10 days pass after we send you the notice of resolution of the appeal against you, unless you have asked for a Medicaid Fair Hearing with continuation of benefits within those ten days
  3. The Medicaid Fair Hearing office issues a hearing decision against you
  4. The time period or service limits of a previously authorized service have been met.

Continuation of Benefits during the Medicaid Fair Hearing Process (Not applicable to MediKids Members)

You can ask that we continue to cover your medical services during the Medicaid Fair Hearing process. To do this: 

  • If you received services during your plan appeal, you must file your request with the Agency of Health Care Administration (Agency)  no later than 10 calendar days from the date on your  Notice of Plan Appeal Resolution letter or on or before the first day that your  services will be reduced, suspended or stopped, whichever is later
  • Your appeal involves an action we're taking to reduce, suspend or stop a service we had already approved
  • The service must have been ordered by an authorized provider
  • The original time period covered by the approval we gave has not yet ended
  • You need to ask for a continuation of benefits

What if the MFH Officer Rules Against the Plan's Action? 

If we did not give you the services you wanted during the appeal or the MFH, we will approve them. We have 72 hours after we receive the notice to change the appeal decision. If you did get the services during the appeal or the MFH, we will pay for them. 

What if the Officer Rules in Favor of the Plan's Action?

If your services continue and our decision is upheld in a fair hearing, we may ask that you pay for those services. We will not take away your benefits. We cannot ask your family or anyone acting for you to pay for the services.

What is a Complaint?

A complaint is when you are unhappy with our plan. It is less formal than a grievance. When you have a complaint, contact us by calling or writing. Call us at 1-866-334-7927 (TTY 711) Monday-Friday, 8 a.m. to 7 p.m.  You can write to us at:

WellCare Health Plans
Attn: Customer Service 
P.O. Box 31370
Tampa, FL 33631-3370

We will resolve your complaint by the close of the next business day. If it takes more time, we will change it to a formal grievance.

What is a Grievance?

A grievance is when you make a formal complaint about us, a provider or a service or any of these issues: 

  • Quality-of-care issues
  • Wait times during provider visits
  • The way your providers or others act or treat you
  • Unclean provider offices
  • Not getting the information you need 

How To File a Grievance

You can file a grievance by calling or writing to us. To do so by phone, call us at 1-866-334-7927 (TTY 711) Monday-Friday, 8 a.m. to 7 p.m. 

To write us, mail to: 

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


You can fax us toll-free at:  1-866-388-1769

Who Can File a Grievance

You can file one yourself. Or you can have someone file one for you. This can be your PCP or another provider. If you need help filing one, call us. 

You may wish to have someone act for you. If so, you must send us a statement you have signed. It must say you allow this person to act for you. To help with this, we have an Appointment of Representative form.  You can find the form online. You can use this form to allow someone to act for you.

When to File a Grievance

You may file one at any time.

Within five business days of getting your grievance, we will mail you a letter. It will tell you we received your grievance. We will send you another letter with our ruling within 60 calendar days; but no more than 90 calendar days. 

You can also request a 14 day extension. You will need to have more information to support your grievance. If we need more time, we will call you to tell you why. We will also let you know by sending you a letter within two calendar days. We will do this if we need more information and it is in your best interest. 

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Last Updated On: 7/18/2018
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