Grievance and Appeals
WHO DO I CONTACT IF I HAVE A PROBLEM OR COMPAINT?
At Simply Healthcare Plans, complaints are sometimes referred to as grievances. A grievance is a complaint or dispute (other than a determination), expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Medicare health plan, or its providers.
A grievance can be filed verbally or in writing within 60 days of the prompting event or incident causing the grievance.
Plans must notify all concerned parties about the results of the investigation as expeditiously as the member’s case requires based on the member’s health status, but no later than 30 days after the grievance is received by the plan. In some cases, the plan may extend the timeframe by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest.
Quality of care grievances may be reported through the plan's grievance procedures, your state Quality Improvement Organization (QIO) or both.
WHAT ARE ORGANIZATION DETERMINATIONS (PART C)?
An organization determination is a decision made by Simply Healthcare Plans regarding:
- Receipt of care or payment for care for a managed care item or service.
- The amount that the plan requires you to pay for an item or service; or
- A limit on the quantity of items or services
You, your representative or any provider that furnishes or intends to furnish services to you, may request an organization determination by filing a request with the plan.
How to Request an Organization Determination
- Expedited and Standard requests may be filed with the plan verbally or in writing.
How a Health Plan Process Organization Determination Requests
- Notification of determination will be provided within 72 hours for expedited organization determination requests
- Standard organization determinations decisions will be communicated within 14 calendar days
WHAT IS A PART C APPEAL?
You may request an appeal when you are dissatisfied with the decision the plan has made about an organization determination review. An appeal is a formal way of asking the plan to review and change an organization determination decision the plan has made.
There are five levels in the Medicare Part A and Part B appeals process:
- First Level: Reconsideration by health plan
- Second Level: Reconsideration by an Independent Review Entity (IRE)
- Third Level: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals
- Fourth Level: Review by the Medicare Appeals Council (MAC)
- Fifth Level: Judicial Review in Federal District Court
WHAT IS A PART C RECONSIDERATION?
If Simply Healthcare Plans denies an enrollee's request for an item or service in whole or in part (issues an adverse organization determination), the enrollee or the enrollee’s representative may appeal the decision to the plan by requesting a reconsideration.
An enrollee's physician may request an expedited or a standard reconsideration, without being appointed as the enrollee's representative, on the enrollee's behalf. If a physician requests the expedited reconsideration, plans are required to expedite the request.
How do I request a reconsideration
Reconsideration requests must be filed with the Simply Healthcare Plans within 60 calendar days from the date of the notice of the organization determination.
- Expedited requests can be made either verbally or in writing
- Standard requests must be made in writing
If the enrollee or the enrollee’s representative requires assistance with reconsiderations please contact the Member Services Department at 1-877-577-0115. (if you use a TTY device call 711). We are open 7 days a week, 8 a.m to 8 p.m.
Coral Gables, FL 33134
Attn: Grievance/Appeals Department
Fax number: 1-877-577-0114
Call 1-877-577-0115 (TTY 711)
We are open 7 days a week, 8 a.m to 8 p.m.
