• Overview
• Grievances (Complaints)
  • Making a Complaint
• Problems/Concerns about Part C Medical Benefits and Coverage
  • Coverage Decisions
  • Appeal a Coverage Decision
• Problems/Concerns about the Part D Prescription Drug Benefit
  • Coverage Decision/Exceptions
  • Appeal a Coverage Decision

HOW TO APPEAL A COVERAGE DECISION

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LEVEL 1 APPEAL

How to ask for a review of a medical care coverage decision OR payment for medical care coverage decision made by our plan.

If we say "No" to your request for coverage of medical care that you have not already received OR to your request for payment of a claim for services that you have already received you have the right to ask us to reconsider and perhaps change this decision by making an appeal. If you decide to make an appeal, it means you are going to Level 1 of the appeals process.

• You, your authorized representative or in some cases your doctor must contact our plan. You can give written permission to someone else to act as your representative. You can utilize the Appointment of Representative form that gives a person legal permission to be your appointed representative. You can also have a lawyer act on your behalf.
• Make your "Standard" appeal request in writing, by submitting a signed request to:
  

  Florida Health Care Plans
  Attn; Member Services
  1340 Ridgewood Avenue
  Holly Hill, FL 32117
  Fax#: 386-676-7149

• If your health requires a quick response, you can request a "Fast" appeal. You may make your request by phone or in writing. To make your request by phone, call 1-877-615-4022. Hearing Impaired call TRS Relay 711. If your health requires it you can make a "fast" appeal.
• You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Our plan considers your appeal and we give you our answer:
Deadlines for a "fast" appeal

• We must give you our answer within 72 hours after we receive your appeal.
  • However, if you ask for more time, or if we need to gather more information that may be beneficial to you, we can take up to 14 more days.
  • If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days) we are required to send your request to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours.
  • If our answer is No to part or all of what you requested, we will send you a written notice informing you we have sent your appeal to the Independent Review Organization for a Level 2 appeal.

Deadlines for a "Standard" appeal (MEDICAL CARE COVERAGE DECISIONS)

• We must give you our answer within 30 calandar days after we receive your appeal.
  • However, if you ask for more time, or if we need to gather more information that may be beneficial to you, we can take up to 14 more days.
  • If we do not give you an answer within 30 calandar days(or by the end of the extended time period if we took extra days) we are required to send your request to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours.
  • If our answer is No to part or all of what you requested, we will send you a written notice informing you we have sent your appeal to the Independent Review Organization for a Level 2 appeal.

Deadlines for a "Standard" appeal (REQUEST FOR PAYMENT)
(You can not request a "fast" appeal for payment for a medical service you have already received.)

• We must give you our answer within 60 calendar days after we receive your appeal.
  • If we do not give you an answer within 60 calendar days (or by the end of the extended time period if we took extra days) we are required to send your request to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization.
  • If our answer is yes to part or all of what you requested, we must send the payment you requested to your or the provider within 60 calendar days.
  • If our answer is No to part or all of what you requested, we will send you a written notice informing you we have sent your appeal to the Independent Review Organization for a Level 2 appeal.

LEVEL 2 APPEAL:

If our plan says no to your Level 1 appeal for Medical coverage or payment of a medical covered service, your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the decision our plan made when we said no to your first appeal. This organization decides whether the decision we made should change.

• The Independent Review Organization is an outside, independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the Independent Review Organization. Medicare oversees its work. If the Independent Review Organization will notify you and the plan of their decision.
• If the Independent Review Organization rules in your favor the plan must provide the service or payment you requested within specified timeframes. (see your Evidence of Coverage for details on these timeframes)
• If the Independent Review Organization does not rule in your favor and the service or payment you requested meets a specific dollar amount they will notify you of your right to a Level 3 appeal and you would file your request for Level 3 appeal to the Administrative Law Judge.

LEVELS 3, 4 AND 5 OF THE APPEAL PROCESS:

If your appeal is denied by the Administrative Law Judge payment you requested meet specific dollar amounts you will be advised at each level of the appeal process any additional levels of appeal you may be entitled to, Levels 3,4, and 5.

For additional information on this process and for more detailed information on Part C - Medical Coverage Appeals:

• Members of the Medvantage Plan please refer to Chapter 7 of your Evidence of Coverage for complete information on requesting a coverage decision.
• Members of the Medvantage RX Plan please refer to Chapter 9 of your Evidence of Coverage for complete information on filing a grievance.
• Members of the Medvantage RX Plus Plan please refer to Chapter 9 of your Evidence of Coverage for complete information on filing a grievance.

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