Appeals and Grievances

Complaints

If you are not happy with a choice made by Sunshine Health, you have the right to file a complaint over the telephone or in writing by contacting Sunshine Health's Member Services Department. All complaints must be solved in a timely manner as soon as possible.

If you are not happy with the choice made on your complaint, or if it takes more than 1 working day to solve a complaint, you may file a formal grievance with Sunshine Health. If any complaint is not solved within 1 working day, it is deemed a grievance. If you want to file a formal grievance, call Member Services with your information and they can help you file a written grievance. The representative will make clear the grievance process and complete the needed info. You will get proof that your grievance is under review. Sunshine Health will solve formal grievances about urgent care or emergency care within 72 hours.

Filing a Grievance

We hope our enrollees will always be happy with Sunshine Health and our doctors. If you are not happy, please let us know. This includes if you do not agree with a choice we have made about paying for your care. A grievance is an expression of dissatisfaction about any matter other than an action.

You have the right to file a grievance within 1 year after the event occurred.  A provider may file a grievance on your behalf with your written consent.

To file a grievance you can:

Call Member Services 8 a.m. to 8 p.m. Monday through Friday (ET) at 1-866-796-0530 (TDD/TTY 1-800-955-8770).

Or write us a letter telling us why you are not happy.  Be sure to include:

  1. Your first and last name
  2. Your Enrollee ID card number
  3. Your address and telephone number

Mail the letter to:

Sunshine Health Long Term Care
Appeal and Grievance Coordinator
1301 International Parkway
Suite 400
Sunrise, FL 33323
Fax 1-866-534-5972

If you would rather have someone speak for you, let us know. Another person can act for you.  You have the right to review your grievance file at any time.

When will Sunshine Health tell me the outcome about my grievance?

Sunshine Health will send you a letter telling you that we received your grievance within 5 days within days. We will try to make a decision right away.

Sometimes we can resolve it on the phone. If not, we will give you a written decision within 90 calendar days after we get your grievance.

If Sunshine Health needs extra time to resolve the grievance (or if you request more time), we will add 14 calendar days to the timeframe.

Medicaid Fair Hearing for Grievances

What if I am still not happy?

If you are still unhappy with our choice on your grievance, you may request a Medicaid Fair Hearing.  You or your provider may request a Medicaid Fair Hearing at any time.

If you request a Medicaid Fair Hearing and want your benefits to carry on, you must file your request within 10 days from the date we sent you our choice.  If the Medicaid Fair Hearing finds that our choice was right, you may be in charge for the cost of the continued benefits.

To request a Medicaid Fair Hearing, please write to:

The Office of Appeal Hearings
1317 Winewood Boulevard, Building 5, Room 255
Tallahassee, Florida 32399-0700

Filing an Appeal

An appeal is a request to review a Notice of Action. This review makes us look again at the services not being given as requested. You can request this review by phone or in writing.

Actions occur when Sunshine Health:

  • Denies the care you want
  • Reduced the amount of care
  • Ends care that has already been approved
  • Denies payment for care and you may have to pay for it

You will know that Sunshine Health is taking an action because we send you a letter. The letter is called a Notice of Action. If you do not agree with the action, you may request an Appeal.

Who can file an Appeal?

  • Sunshine Health enrollee
  • A person named by the Sunshine Health enrollee
  • A provider acting for a enrollee

You must give written permission if a provider files an appeal for you. Sunshine Health will include a form in the Notice of Action letter. Contact us if you need help. We will assist you in filing an appeal.e of Action letter. Contact us if you need help. We will assist you in filing an appeal.

When does an Appeal have to be filed?

The Notice of Action will tell you about this process. You may file an appeal within 30 days from the date of the Notice of Action. If you do not get a letter, you have 1 year to file an appeal.  If you make your request by phone or in person, you must also send Sunshine Health a letter as proof of your request. You can receive care about your review while we decide on the appeal of a suspended authorization.  However, you may have to pay for this care, if the outcome is not in your favor. You may ask to keep getting care about your review while we decide. You may have to pay for this care, if the outcome is not in your favor.

Sunshine Health will give you a written decision within 45 days from the date of your request. If more than 45 days is needed to make a decision, we will send a letter to you. Sunshine Health will ask for extra time if more information is needed.  The extra time may be better for your case. Sunshine Health will ask for an extra 14 days in writing. The letter will say why we need more time. You have the right to review your appeal file at any time.

Medicaid Fair Hearing for Appeals

What if I am still not happy?

If you are not happy with our choice on your appeal, you may request a Medicaid Fair Hearing.  You or your provider may request a Medicaid Fair Hearing at any time.

If you request a Medicaid Fair Hearing and want your benefits to continue, you must file your request within 10 days from the date we sent you our decision.  If the Medicaid Fair Hearing finds that our decision was right, you may have to pay for this care. 

To request a Medicaid Fair Hearing, please write to:

The  Office of Appeal Hearings
1317 Winewood Boulevard, Building 5, Room 255
Tallahassee, Florida 32399-0700

Beneficiary Assistance Program (BAP) for Appeals

You also have a right to request a review with the Beneficiary Assistance Program. You must request this review with the Beneficiary Assistance Program within one year from the receipt of our decision letter. If you request a review with Medicaid Fair Hearing, your grievance will not be reviewed by the Beneficiary Assistance Program.

Please include your name, enrollee ID#, address and the reason for your appeal to:

Agency for Health Care Administration
Beneficiary Program (BAP)
Building 1, MS #26
2727 Mahan Drive,
Tallahassee, Florida 32308

You can also call them at 1-850-412-4502 or toll free 1-888-419-3456

Expedited Appeals

You or your doctor may want us to make a fast decision. You can ask for an Expedited Review if you feel that your physical or mental health is at risk. If you feel this is needed, call our Appeal and Grievance Coordinator at 1-866-796-0530 (TDD/TTY 1-800-955-8770) 8 a.m. to 8 p.m. Monday through Friday. We will decide within three working days. However, the review period may be up to 14 days. You will also receive a letter telling the reason for the decision and what to do if you do not like the decision. If you are still unhappy with the decision on your expedited appeal, you have a right to file a Medicaid Fair Hearing with the state.