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Grievances and Appeals

Complaint

A complaint is the lowest level of problem resolution and provides Sunshine Health an opportunity to resolve a problem without it becoming a formal grievance. If a complaint is not resolved by close of business within a day after it is received, it will be moved into the grievance system.

Grievance

A grievance is an expression of dissatisfaction about any matter other than an “action.” For example, a member may file a grievance regarding issues such as:

  • Appointment waiting times
  • Quality of care
  • The behavior of a doctor or his/her staff
  • Wait times to be seen while in a doctor’s office

Sunshine Health must resolve grievances within 90 days of receipt of the grievance.

Appeal

An appeal is a request for a review of an action, which may include:

  • Denial, reduction, suspension or termination of a service already authorized
  • Denial of all or part of the payment for a service

Sunshine Health must resolve the standard appeal within 30 days and an expedited appeal within 72 hours.

Providers may request an “expedited plan appeal” on their patients’ behalf if they believe that waiting 30 days for a resolution would put their life, health or ability to attain, maintain or regain maximum function in danger. If Sunshine Health does not feel that request qualifies as expedited, Sunshine Health will notify the member of the decision and will process the plan appeal under standard time frames. Expedited requests do not require a member’s written consent for the providers to appeal on the member’s behalf.

During the appeal process, the member has the right to keep getting the service that is scheduled to be reduced, suspended or terminated until a final decision is made as long as the appeal request is made within 10 days of the date of the denial letter.

A member may file a grievance or appeal verbally or in writing at any time by:

  • Email Sunshine_Appeals@centene.com
  • Fax 1-866-534-5972
  • Call member services from 8 a.m. to 8 p.m. Monday through Friday at the following numbers based on the member’s line of business
    • MMA and Comprehensive members: 1-866-796-0530
    • CWSP members: 1-855-463-4100
    • TDD/TTY line for all members: 1-800-955-8770
  • Send a written request by mail to:
    Grievance and Appeals Coordinator
    Sunshine Health
    1301 International Parkway
    Suite 400
    Sunrise, FL 33323

If a member files an appeal by phone, Sunshine Health sends the member a reminder to file a written appeal within 10 business days of receiving the verbal request.

Medicaid fair hearings may be requested any time up to 120 days following the date on the notice of plan appeal resolution. The member must finish the appeal process first.

Medicaid fair hearings may be requested through any of the following methods:

  • Email MedicaidFairHearingUnit@ahca.myflorida.com
  • Fax 1-239-338-2642
  • Phone 1-877-254-1055
  • Send a written request by mail to the following address:
    Agency for Health Care Administration
    Medicaid Hearing Unit
    P.O. Box 60127
    Ft. Myers, FL 33906