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Non-Participating Provider Appeal Rights

According to the guidelines of the Centers for Medicare and Medicaid Services (CMS) providers not participating with Simply Healthcare Plans have the right to appeal. Non-Participating providers may file standard appeals in writing within 60 calendar days after the date of the Plan’s notification date.  The time can be extended if the non-participating provider can provide evidence for what prevented him/her from meeting the deadline.

For us to review your appeal, we will need your completed signed Waiver of Liability Statement. This form ensures that the enrollee is held harmless regardless of the outcome of the appeal. The following documentation should be included with your appeal: Copy of the original claim, Explanation of Payment (EOP), and any clinical records and other documentation that supports your request. Once we receive the completed form, we will give you a decision on your appeal within 60 calendar days.

Waiver of Liability Statement

You may mail or fax your written appeal to:

Simply Healthcare Plans, Inc.
Attn: Grievance & Appeals Department
9250 W. Flagler Street, Suite 600
Miami, FL 33174-3460
Fax number: 1-866-887-8943

What Happens Next?

If you appeal, we will review our initial decision. If payment for any of your claims is still denied, we will forward your appeal to the Centers for Medicare & Medicaid Services Independent Review Entity (IRE) -MAXIMUS FEDERAL SERVICES for a new and impartial review. If the IRE upholds our decision, you will be provided with further appeal rights as appropriate. 

Last Updated: 
November 1, 2017