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Complaints & Grievances

Complaints

If you are not happy with our care or services, call Member Services at the number below. Please press 1 to speak to a person. We will try to resolve your issue. We will answer your questions. If you are still not happy, you can file a complaint. A complaint becomes a grievance after 24 hours if not resolved. You can file a complaint about many things. Here are a few examples:

  • A doctor was rude to you.
  • You are unhappy with the quality of care you received.
  • You had to wait too long to see your doctor.
  • You are not able to get information from the plan.
  • You are concerned about your privacy or medical records.

Grievances

You can file a formal grievance orally or in writing. Your doctor can file it for you if you give your okay in writing. You may file your grievance at any time after the incident. Call Member Services if you need help. If you are deaf or blind, call our TDD line at 1-800-955-8771. Member Services is open between 8:00am and 5:00pm EST. You can talk with the Grievance Coordinator. Ask for a Grievance Coordinator from 8:00am to 5:00pm EST Monday to Friday.

You can mail a written grievance and any documentation you want to send with it to:

Ped-I-Care Grievance Coordinator
1699 SW 16th Avenue
Gainesville, FL 32608-1153
Fax: 352-294-8075
pedicaregrievances@peds.ufl.edu

We will send you a letter within five days after we received your grievance filed orally or in writing. If you request an expedited resolution, we will not send a letter. We will look at you grievance carefully. We have up to 90 days to take care of your grievance.

We might need more time if we need more information. We can take up to 14 more days to review if it is in your best interest. We will send you a letter telling you about this within two days. The letter will include our reason for needing more time. If you need more time, you can ask for up to 14 more days. You can let us know in writing or by calling us. The extension is only for 14 calendar days in addition to the 90 days to review and resolve your grievance.

After we review your grievance, we will send you a letter with what we found. If you are not happy with what we told you, you can ask for a plan appeal.

Plan Appeals

If you are not happy with a “Notice of Adverse Benefit Determination” (NABD) from the Children’s Medical Services Managed Care Plan (CMS Plan Ped-I-Care), you can appeal. A Notice of Adverse Benefit Determination is/means:

  • The service you have been getting is stopped, reduced or changed;
  • Medicaid will not pay for the service you asked for;
  • You did not get the services you need quickly enough, per the Florida law.

When you get our Notice of Adverse Benefit Determination (NABD) letter, you have 60 days to send your plan appeal from the date of the ABD letter. You can file a plan appeal by phone or in writing. If you file a plan appeal by phone, you MUST then send your plan appeal to us in writing within 10 days or the phone plan appeal request will not be accepted. Your doctor can file a plan appeal for you, but he/she must have your okay in writing. You may want to send other information with your written plan appeal. You can also ask your doctor for documentation. The written plan appeal needs to have member’s name, member’s identification number and phone number where we can reach a parent or legal guardian. You can tell us why we should change the decision, any medical information to support your request and who you would like to help your plan appeal. You can mail it to:

Ped-I-Care Utilization Management (UM) Department
1699 SW 16th Avenue
Gainesville, FL 32608-1153

You can Fax to: 1-352-294-8084

Or you can call us at 1-866-376-2456 and ask for the UM Appeal Coordinator from 8:00 a.m. to 5:00 p.m. (EST) Monday to Friday.

We will tell you when we get your plan appeal. We will send you a letter within five days. We will look at your plan appeal carefully. We have up to 30 days to take care of your plan appeal. If you filed a plan appeal by writing only, the 30 days starts from the day we receive your letter. If you filed a plan appeal by phone and then by letter, the 30 days start from the day you called.

We might need more time if we need more information. We can take up to 14 more days to review if it is in your best interest. We will call you on the day we decide we need more time and we will send you a letter telling you about this within two days. The letter will include our reason for needing more time. If you need more time, you can ask for up to 14 more days. You can let us know in writing or by calling us. The extension is only for 14 calendar days in addition to the 30 days to review and resolve your plan appeal.

A doctor who did not make the original decision will read your plan appeal carefully. We have up to 30 days to take care of your plan appeal.  We will send you a letter with our decision.

You can request an expedited plan appeal if you need a faster review because of your health. This is called an “Expedited Plan Appeal Review.” If you or your provider think that waiting 30 days for a decision could put your life, health or your ability to attain, maintain, or regain maximum function in danger. You can ask for a faster review by phone or by letter but you need to make sure that you ask us to expedite the plan appeal. We will tell you and your provider our answer within 72 hours. We will try to call and let you know our decision. We will also send you a letter within two calendar days after we receive the plan appeal decision. We may not agree that your plan appeal needs to be expedited, but you will be told of this decision. We will still process your plan appeal under normal time frames.

If you are not happy with what we told you, you can ask for a Medicaid Fair Hearing or the Subscriber Assistance Program.

During our review, you can give us information to help your case. You can give it to us in person or by letter. You can also look at your file any time before a decision is made. Your file may have medical or other documents that we will use.

Medicaid Fair Hearing (MFH)

You do not have to wait for us to make our appeal decision. You can ask for an MFH anytime. If you choose an MFH before completing our grievance and appeal process, you have 90 days from our notice of action. You can wait for our answer first. If you are not happy with what we tell you, you have 90 days from our final decision letter to ask for an MFH. If you choose an MFH before completing our grievance and appeal process, you cannot go back to our grievance and appeal process after the MFH.

You can ask for an MFH by contacting:

Agency for Health Care Administration
Medicaid Hearing Unit
P.O. Box 60127
Ft. Myers, FL 33906
(877) 254-1055 (toll-free)
239-338-2642 (fax)

MedicaidHearingUnit@ahca.myflorida.com

You will receive a letter from the Medicaid Hearing Unit. It will tell you when the MFH will take place. You can have someone speak for you at the hearing. If you want your doctor to speak for you at the hearing, you need to check with your doctor. In addition, you will need to inform the Hearing Officer.

Continuation of Benefits

You can ask us to continue your care during a plan appeal or MFH. If the final decision is in favor of CMS Plan (Ped-I-Care) and the denial of service stays, you may have to pay for the cost of the services. You may need to return the money for services paid while the plan appeal was pending if the services were continued only because of this request and decision is not in your favor.

To continue your benefits, you must ask to continue benefits and:

  • The plan appeal must involve the ending, suspension or reduction of a previously authorized service;
  • The authorization must not have expired; and
  • The services must be ordered by a CMS Plan (Ped-I-Care) provider.

To continue the services during the plan appeal process, you must ask to continue benefits and ask for benefits within this time frame:

  • Send us a letter no later than 10 calendar days from the date of the CMS Plan (Ped-I-Care) Notice of Adverse Benefit Determination; or
  • On or before the first day that your services are scheduled to be reduced, suspended, or terminated, whichever is later.

We will continue the services until one of the following happens:

  1. You ask us to stop looking at your plan appeal.
  2. More than 10 days have passed from the date on your notice of plan appeal resolution letter, and you have not asked to continue services
  3. The decision from the Medicaid Fair Hearing is in favor of CMS Plan (Ped-I-Care).
  4. The authorization ended or the authorized services are not met
  5. The MFH office denies your plan appeal after the hearing is held

Subscriber Assistance Program (SAP)

After completing the CMS’s grievance and plan appeals system and you are still not happy with the decision, you can ask for a review by SAP. You must ask for the review within one year of our final notice of plan appeal resolution letter. If you ask for a fair hearing, you cannot have a SAP review.

You can ask for a review by writing to:

Agency for Health Care Administration
Subscriber Assistance Program
Building 3, MS #45
2727 Mahan Drive
Tallahassee, Florida 32308

Call toll-free 1-888-419-3456 or (800-955-8771 Florida Relay Service TDD number)

Medicaid Helpline

You can file a complaint about a Health Plan or a Health Care Facility by calling the Medicaid Helpline at (888) 419-3456 / (800) 955-8771 Florida Relay Service (TDD number) Monday – Friday, 8:00 A.M. to 5:00 P.M., EST. or online at: https://apps.ahca.myflorida.com/smmc_cirts/

Non Discrimination Compliance Coordinator

Children’s Medical Services Plan (Ped-I-Care) complies with applicable Federal Civil Rights Laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Call member services at 1-866-376-2456 if you feel you’ve been discriminated. Ask for the Grievance Coordinator. Call member services if you have access issues.

The cultural and linguistic competence plan is available to you. There is no charge. This plan helps us serve you better. The plan is online. The address is http://pedicare.pediatrics.med.ufl.edu/about-us/cultural-linguistic-competence-plan/. You can ask for a paper copy. Call 1-866-376-2456.