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Grievance and Appeal

WHAT IS A GRIEVANCE?

A grievance is a complaint or dispute, other than one involving an organization 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. You may file an Expedited Grievance in the event you disagree with the refusal to expedite an Organization Determination or Reconsideration request or we extend the processing timeframe for an Organization Determination or a Reconsideration. A resolution will be provided to you within 24 hours.

WHO DO I CONTACT IF I HAVE A PROBLEM OR COMPLAINT?

If you or your authorized representative would like to file a written or oral grievance you may submit your request to our Grievance and Appeals Department at the following address, telephone number or fax:

Simply Healthcare Plans
Attn: Grievance/Appeals Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-866-887-8943
 

From October 1 to March 31, we are open 7 days a week from 8 a.m. - 8 p.m., EST. Beginning April 1 until September 30, we are open Monday through Friday, 8 a.m. - 8 p.m., EST.

Plans must notify all concerned parties regarding 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. However, if the plan needs more information and the delay is in your best interest or if you ask for more time, we can take up to an additional 14 calendar days (44 calendar days total) to resolve your grievance.

Quality of Care grievances may be reported through our grievance procedures, your state Quality Improvement Organization (QIO) or both.

Grievance Form (English / Spanish)

 

WHAT ARE ORGANIZATION DETERMINATIONS (PART C)?

An organization determination is a decision made by us Simply Healthcare regarding:

1.     Receipt of care or payment for care for a managed care item or service.
2.     The amount we require you to pay for an item or service; or
3.     A limit on the quantity of items or services.

You, your authorized representative or any provider who furnishes or intends to furnish services to you, may request an organization determination by filing a request with Simply Healthcare.

HOW TO REQUEST AN ORGANIZATION DETERMINATION

Expedited and Standard requests may be filed verbally or in writing.

Simply Healthcare Plans
Attn: Utilization Management
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
 

HOW A HEALTH PLAN PROCESSES ORGANIZATION DETERMINATION REQUESTS

Notification of determination will be provided within 72 hours for expedited organization determination requests. However, under certain circumstances, we can take up to an additional 14 calendar days.

If we need additional time to make the decision, we will tell you in writing.

Standard organization determinations decisions will be communicated within 14 calendar days. However, the plan can take an additional 14 calendar days if you ask for additional time, or if we need information that may benefit you.
You may file an Expedited Grievance in the event you disagree with us extending the process timeframe for an Organization Determination. A decision will be made within 24 hours.
 

WHAT IS A PART C APPEAL?

You may request an appeal when you are dissatisfied with the decision we have made about an organization determination decision. An appeal is a formal way of asking us to review and change an organization determination decision we have made.

There are five levels in the Medicare Part C 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 authorized representative may appeal the decision to us by requesting 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 reconsideration?

Reconsideration requests must be filed with Simply Healthcare Plans within 60 calendar days from the date of the notice of the organization determination.

- Standard or expedited service requests can be made either verbally or in writing.

If you or your authorized representative requires assistance with reconsiderations please call Member Services toll-free at 1-877-577-0115 (TTY 711). From October 1 to March 31, we are open 7 days a week from 8 a.m. - 8 p.m., EST. Beginning April 1 until September 30, we are open Monday through Friday, 8 a.m. - 8 p.m., EST.

If you or your authorized representative would like to file an appeal in writing you may submit your request to our Appeals Department at the following address, telephone number or fax:

Simply Healthcare Plans
Attn: Grievance/Appeals Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Call: 1-877-577-0115 (TTY 711)
Fax number: 1-866-887-8943

How Simply Healthcare Processes Reconsideration Requests

Once we receive the request, we will notify you of our decision as quickly as your health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard service requests (the plan can take up to an additional 14 calendar days if you request additional time, or if we need additional information that may benefit you), or 60 calendar days for payment requests.

If the decision is unfavorable to you, in whole or in part, the plan must automatically submit the case file and its decision for automatic review by the Part C Independent Review Entity (IRE).

 

For instructions and access to the CMS Appointment of Representation Form (Form CMS-1696), click on the link below:

 

Last Updated: 
October 1, 2018