Simply Healthcare Plans Member Appeal Process Guide
This file outlines the steps members of Simply Healthcare Plans need to follow to appeal a decision regarding their Medicaid Managed Medical Assistance or Long-Term Care services. It provides detailed information on how to file an appeal, what to expect after submitting an appeal, and what to do if expedited processing is needed. The guide also includes contact information for further assistance.
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How do I fill this out?
To fill out this form, gather any necessary medical records and information related to the appeal. Then, choose one of the methods provided (mail, fax, email, or call) to submit your appeal request. Be sure to follow the specific instructions for your type of service and contact the grievance and appeals coordinator if you need assistance.
How to fill out the Simply Healthcare Plans Member Appeal Process Guide?
1
Gather necessary medical records and information.
2
Choose a submission method: mail, fax, email, or call.
3
Submit your appeal request according to the instructions for your service type.
4
Contact the grievance and appeals coordinator if needed.
5
Wait for confirmation and further instructions from Simply Healthcare Plans.
Who needs the Simply Healthcare Plans Member Appeal Process Guide?
1
Members who have had a service denied, limited, reduced, suspended, or terminated and wish to appeal the decision.
2
Family members or friends helping a member with the appeal process.
3
Healthcare providers assisting a member with their appeal.
4
Lawyers representing a member in their appeal process.
5
Simply Healthcare Plans staff who need to inform members about the appeal process.
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What are the instructions for submitting this form?
Submit your appeal by mailing your request and medical information to: Medical Appeals, Grievance and Appeals Coordinator, Simply Healthcare Plans, Inc., 4200 W. Cypress St., Ste. 900, Tampa, FL 33607-4173. Alternatively, fax your request and medical information to 1-866-216-3482 or email it to flmedicaidgrievances@simplyhealthcareplans.com. You can also call the grievance and appeals coordinator during business hours based on your type of service for further assistance. Ensure that all required information and documentation are included in your submission for processing.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, the important dates for this form include the deadlines for filing an appeal (within 60 calendar days of receiving the Notice of Adverse Benefit Determination letter) and requesting a Medicaid fair hearing (within 120 calendar days of the decision letter).
What is the purpose of this form?
The purpose of this form is to guide Simply Healthcare Plans members through the process of appealing a decision regarding their Medicaid Managed Medical Assistance or Long-Term Care services. This guide provides detailed instructions on how to file an appeal, what to expect after submitting an appeal, and steps for requesting expedited processing if needed. Additionally, it includes contact information for further assistance and guidelines on how to maintain services during the appeal process to ensure members receive the care they need while their appeal is being reviewed.
Tell me about this form and its components and fields line-by-line.
- 1. Medical Appeals Address: The physical address to send your appeal request and medical information.
- 2. Fax Number: The fax number to send your appeal request and medical information.
- 3. Phone Numbers: Contact numbers for different types of services to speak with the grievance and appeals coordinator.
- 4. Email Address: The email address to send your appeal request and medical information.
- 5. Notice of Adverse Benefit Determination: The letter you receive informing you of denied, limited, reduced, suspended, or terminated services.
What happens if I fail to submit this form?
If you fail to submit this form within the required timeframes, you may lose the right to appeal the decision and could be responsible for the denied services.
- Loss of Appeal Rights: Failing to appeal within 60 calendar days means you waive your right to contest the decision.
- Financial Responsibility: You may become responsible for the costs of the denied services if you do not appeal.
How do I know when to use this form?
- 1. Service Denial: When a requested service is denied by Simply Healthcare Plans.
- 2. Service Reduction: When an approved service is reduced in scope or duration.
- 3. Service Suspension: When a service is temporarily suspended.
- 4. Service Termination: When a service is permanently terminated by Simply Healthcare Plans.
- 5. Request Expedited Appeal: When you need a fast-tracked appeal due to potential serious harm.
Frequently Asked Questions
How do I file an appeal with Simply Healthcare Plans?
You can file an appeal by mail, fax, email, or phone. Follow the instructions provided in the file for your specific service type.
What information do I need to provide in my appeal?
Include any relevant medical records, information about the denied service, and your contact information.
How long do I have to file an appeal?
You must file an appeal within 60 calendar days from the date you received the Notice of Adverse Benefit Determination letter.
Can someone else help me with my appeal?
Yes, a family member, friend, healthcare provider, or lawyer can assist you.
What happens after I submit my appeal?
Simply Healthcare Plans will send you a letter within five business days confirming receipt of your appeal and will notify you of the ruling within 30 calendar days.
Can I request an expedited appeal?
Yes, you can request an expedited appeal if the standard appeal process time could cause serious harm to your life, health, or ability to attain, maintain, or regain maximum function.
How do I contact Simply Healthcare Plans for assistance?
You can contact Simply Healthcare Plans by calling the grievance and appeals coordinator at the provided phone numbers during business hours.
Can I keep receiving services during my appeal?
If your services were reduced, suspended, or terminated, you must call Simply Healthcare Plans within ten business days to request continuation of services during your appeal.
What if Simply Healthcare Plans still will not pay?
You have the right to request a Medicaid fair hearing. This must be done within 120 calendar days of receiving the letter stating Simply Healthcare Plans will not pay for a service.
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