Complaints, Grievances and Appeals

Filing an Expedited or "Fast" Appeal

You or your representative can request an expedited appeal verbally or in writing.

Expedited or “fast” appeals can be considered when:

• Your child is currently receiving treatment and the medical provider believes a delay in treatment could seriously jeopardize your child's life or overall health, affect your child's  ability to regain maximum functions, or subject your child  to severe and intolerable pain. (Your child has a life- or limb-threatening condition.)
• The issue is related to an admission or continued inpatient stay and your child has not yet been discharged.

Continuation of Benefits for Medicaid Members

If your child is now getting a service that is going to be reduced, suspended or terminated, your child has the right to keep getting those services until a final decision is made for your Plan appeal or Medicaid fair hearing.

If your child's services are continued, there will be no change in your child's services until a final decision is made.

If your child's services are continued and our decision is not in your favor, we may ask that you pay for the cost of those services. We will not take away your child's Medicaid benefits. We cannot ask your family or legal representative to pay for the services.

To have your child's services continue during your appeal or fair hearing, you must file the appeal and ask to continue services within this time frame, whichever is later:

• Within 10 days of the date on Notice of Adverse Benefits Determination (NABD), or
• On or before the first day that your child's services will be reduced, suspended or terminated.

Medicaid Fair Hearings (for Medicaid Members)

You may ask for a fair hearing at any time up to 120 days after you get a Notice of Plan Appeal Resolution by calling or writing to:

Agency for Health Care Administration
Medicaid Fair Hearing Unit
P.O. Box 60127
Fort Myers, FL 33906
1-877-254-1055 (toll-free)
1-239-338-2642 (fax)

MedicaidFairHearingUnit@ahca.myflorida.com

If you request a fair hearing in writing, please include the following information:

• Your child's name
• Your child's member number
• Your child's Medicaid ID number
• A phone number where you or your representative can be reached

You may also include the following information, if you have it:

• Why you think the decision should be changed
• Any medical information to support the request
• Who you would like to help with your fair hearing

After getting your fair hearing request, the Agency will tell you in writing that they got your fair hearing request. A hearing officer who works for the State will review the decision we made.

If you are a Title XXI MediKids member, you are not allowed to have a Medicaid Fair Hearing.

Review by the State (for MediKids Members)

When you ask for a review, a hearing officer who works for the State reviews the decision made during the Plan appeal. You may ask for a review by the State any time up to 30 days after you get the notice. You must finish your appeal process first.

You may ask for a review by the State by calling or writing to:

Agency for Health Care Administration
P.O. Box 60127
Fort Myers, FL 33906

1-877-254-1055 (toll-free)
1-239-338-2642 (fax)

MedicaidHearingUnit@ahca.myflorida.com

After getting your request, the Agency will tell you in writing that they got your request.