The grievance process allows the member, (or the member’s authorized representative (family member, etc.) acting on behalf of the member or provider acting on the member’s behalf with the member’s written consent), to file a grievance either orally or in writing. A member grievance is defined as any member expression of dissatisfaction about any matter other than an “adverse action.”
The member will be allowed 30 calendar days from the date of notice of action or inaction to file a grievance or appeal. Sunshine Health shall acknowledge receipt of each grievance in the manner in which is received. Any individuals who make a decision on grievances will not be involved in any previous level of review or decision making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Sunshine Health shall ensure that the decision makers are healthcare professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406] Sunshine Health values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf.
Grievance Resolution Time Frame
Grievance Resolution will occur as expeditiously as the member’s health condition requires, not to exceed 30 calendar days from the date of the initial receipt of the grievance. Expedited grievance reviews will be available for members in situations deemed urgent, such as a denial of an expedited appeal request, and will be resolved within 72 hours.
Medical Necessity Appeals
An appeal is the request for review of a “Notice of Adverse Action.” A “Notice of Adverse Action” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service excluding technical reasons; the failure to render a decision within the required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(2)(ii) to obtain services outside the Sunshine Health network.
Appeal Resolution Time Frame
The review may be requested in writing or orally, however oral requests for appeals within the standard timeframe must be resolved within 30 days of receipt of the appeal, with a 14 day extension possible if additional information is required. Members may request that Sunshine Health review the Notice of Adverse Action to verify if the right decision has been made. Expedited appeals may be filed when either Sunshine Health or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals.
Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the initial receipt of the appeal. Sunshine Health may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Sunshine Health provides evidence satisfactory to the Department of Health Services (DHS) that a delay in rendering the decision is in the member’s interest. For any extension not requested by the member, Sunshine Health shall provide written notice to the member of the reason for the delay. Sunshine Health shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written notice of action.
The member may also find the member complaint form online here.