Florida Health Solution HMO Company (FHS-HMO) has an appeal and grievance procedure which complies with applicable state and federal law ("The Appeal and Grievance Procedure"). We will try to resolve any problems you may encounter over the telephone, but sometimes, additional steps are necessary. In these cases, we have an Appeal and Grievance Procedure available that provides channels for you, or a provider acting on your behalf, to voice your concerns and have them reviewed and addressed at several levels within the Plan.
The Appeals and Grievance Procedure includes informal as well as formal grievance steps. A grievance is not considered formal until a written request for grievance review or a completed FHS-HMO "Formal Grievance/Appeal Form" requesting formal action is received by FHS-HMO's Grievance & Appeal Administrator. You have one year from the date of the event/occurrence upon which the complaint is based to file a verbal or written request for grievance review.
Appeals refer to adverse determinations by FHS-HMO in matters of covered services.
A Grievance refers to matters other than Adverse determination of covered services whether these are informal or formal.
1. Any claim denial, reduction, or termination of, or a failure to provide, or make payment (in whole or in part) for a benefit, including:
a.deductible credits; coinsurance; co-pay; provider network reductions or exclusions, or other cost sharing requirements;
b.any instance where the plan pays less than the total expenses submitted resulting in member responsibility;
c.a benefit resulting from the application of any utilization review;
d.a covered benefit that is otherwise denied as not medically necessary or appropriate;
e.a covered benefit that is otherwise denied as experimental or investigational;
2.Any decision to deny coverage at time of application including placing a medical rider; and
3.Any rescission of coverage, including offering the option of accepting a medical rider in lieu of rescission, (whether or not the rescission has an adverse effect on any particular benefit at that time).
1.A person to whom a member has given express written consent to represent the member;
2.A person authorized by law to provide substituted consent for a member; or
3.A family member of the member or the claimant's treating health care professional when the member is unable to provide consent.
4.For purposes of these procedures a reference to a member may also refer to an authorized representative.
1. The time periods for making non-urgent care review recommendations:
a.could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function; or
b.in the opinion of a physician with knowledge of the member's medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim;
E. "Post-service claim" means any claim for benefits for medical care or treatment that is not a pre-service claim.
F."Rescission" is a cancellation or discontinuance of coverage that has a retroactive effect.
1. Members or their authorized representative have 180 days following receipt of an initial notification of an adverse benefit determination to file for an internal appeal;
2. Members have the right to submit written comments, documents, records, and other information relating to the claim for benefits;
3. Members have the right to review the claim file and to present evidence and testimony as part of the internal review process;
4. Members may request reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits free of charge;
5. All comments, documents, records and other information submitted by the member relating to the claim for benefits, regardless of whether such information was submitted or considered in the initial benefit determination, will be considered in the internal appeal;
6. The member will receive from the plan, any new or additional evidence considered by the reviewer 10 calendar days in advance of the health plans response in order to give the member time to respond;
7. The member will receive from the plan any new or additional medical rationale used to make the decision 10 calendar days in advance of the date of the response so that the member can have time to respond;
8. Review of the appeal will be conducted by an individual selected by the health plan who was not the individual who made the initial adverse benefit determination and is not the subordinate of the original reviewer;
9. A plan that is providing benefits for an ongoing course of treatment cannot be reduced or terminated without providing advance notice and an opportunity for advance review. The plan is required to provide continued coverage pending the outcome of an appeal.
10. The internal appeal process must be exhausted before the member may request an external review; unless the plan provides a waiver of this requirement; fails to follow the appeal process; or files an urgent care external appeal at the same time as an urgent care internal appeal.
B.Medical Judgment: If the adverse benefit determination is based in whole or in part on a medical judgment, the health plan will consult with a health care professional who has appropriate expertise in the field of medicine involved in the medical issue and who was not consulted in connection with the original adverse benefit determination to review the appeal.
C. Rescissions: If the appeal concerns a rescission action, a panel of individuals who were not involved in the original adverse benefit determination will review the appeal.
D. All Other: All other adverse benefit determinations that are not based in whole or in part on a medical judgment, will be reviewed by an impartial person who was not involved in making the original adverse benefit determination.
E. Urgent Care Reviews: Internal review appeals of an adverse benefit determinations involving urgent care will be:
1. Completed as soon as possible, but no longer than within 72 hours of the request; and
2. Members may request an expedited external appeal at the same time the internal expedited review is requested and an Independent Review Organization (IRO), with a plan contracted IRO, and will determine if the internal expedited appeal needs to be completed before proceeding with the expedited external appeal.
A.Post-service appeals: The plan will notify the member in writing with the appeal decision within 60 days after receipt of the claimant's request for internal appeal, unless the plan determines that special circumstances require an extension of time for processing the review. If so, the plan will give the member notice prior to the close of the initial 60-day period noting the special circumstances and the date by which the health plan expects to render the decision.
B.Pre-service appeals: The plan will notify the member in writing with the appeal decision within 30 days after receipt of the claimant's request for internal appeal.
C.Urgent Care appeals: The plan will notify the member within 72 hours of request for internal appeal.
D.These time-frames may be stopped if the health plan is waiting on additional information from the member.
1. The specific reason or reasons for the adverse benefit determination;
2. Reference to the specific plan provision on which the determination is based;
3. A description of any additional material or information necessary for the member to perfect the claim and an explanation of why such material or information is necessary;
4. A description of the external review procedures, including that the member may have a right to bring a civil action under state or federal law;
5. The specific rule, guideline, protocol, or other similar criterion, if used to made the determination, or that it will be provided free of charge upon request;
6. The medical judgment applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request;
7. The date of service;
8. The health care provider's name;
9. The claim amount;
10. The diagnosis and procedure codes with their corresponding meanings, or an explanation that the diagnosis and/or procedure codes are available upon request;
11. The health plan's denial code with corresponding meaning;
12. A description of any standard used, if any, in denying the claim;
13. That assistance is available by contacting the specific state's consumer assistance department, if applicable; and
14. A culturally linguistic statement based upon the claimant's county or state of residence that provides for oral translation of the adverse benefit determination.
B. A copy of the form that authorizes the health plan to disclose protected health information, if applicable.
A. The external review process only applies to adverse benefit determination appeals that involve medical judgment, including but not limited to those based upon requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit; or the determination that a treatment is experimental or investigational, as determined by an external reviewer. The external review process also applies to appeals for rescissions of coverage.
B. After exhausting the internal appeal process, a member has 4 months to request an external review in writing to the health plan after the date of receipt of a notice of an adverse benefit determination, and within 15 days for expedited appeals.
C. Within five 5 business days (immediately for expedited) from the date the health plan receives a request for an external review, the health plan will:
1. Notify and forward to the plan's contracted IRO; and
2. Send the documents and any information considered in making the adverse benefit determination to the plan contracted IRO (via overnight delivery for expedited); or
3. Inform the member in writing that the request does not meet the criteria for external review and include a statement explaining the reason.
D. The plan contracted IRO has 5 days (1 day for expedited) to conduct a preliminary review of the request to determine whether:
1. The individual was a covered person at the time the service was requested; or
2. The service is a covered service under the claimant's health plan but for the plan's adverse benefit determination with regard to medical necessity experimental/investigational, medical judgment or rescission;
3. The member has exhausted the internal process; and
4. The member has provided all of the information required to process an external review.
5. The plan contracted IRO, in accordance with applicable regulations, will immediately notify the member in writing if additional information is required.
E. Within 45 days (72 hours for expedited) after the date of receipt of the request for an external review by the health plan, the plan contracted IRO will review all of the information and provide written notice of its decision to uphold or reverse the adverse benefit determination to the member and the health plan, in accordance with applicable regulations.
F. Upon receipt of a notice of a decision by the plan contracted IRO reversing the adverse benefit determination, the health plan will approve the covered benefit that was the subject of the adverse benefit determination, subject to applicable contract exclusions, limitations, or other provisions.
A. An external review decision is binding on the health plan.
B. An external review decision is binding on the member except to the extent the member has other remedies available under applicable federal or state law.
C. The health plan will pay for the costs of the external review performed by the independent reviewer.
If you have a complaint, please discuss your concern with our Customer Service Department by calling 1-877-827-0711 or visiting FHS-HMO during normal working hours. In accordance with Section 641.47 (5) F.S., a complaint is any expression of dissatisfaction by a Subscriber, including dissatisfaction with the administration, claims practices, or provision of services, which relates to the quality of care provided by a provider pursuant to FHS-HMO's contract and which is submitted to FHS-HMO or to a state agency. Every attempt will be made to resolve your concern during your initial phone call or visit.
If you are not satisfied with our response, you have the right to file a formal written grievance. In accordance with Section 641.47 (10) F.S., a grievance is a written complaint submitted by or on the behalf of a Member or provider to the plan or the agency regarding the: availability, coverage for the delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review; claims payment, handling, or reimbursement for health care services; or matters pertaining to the contractual relationship between a Member or provider and the plan or agency.
You may write us a letter specifically requesting a grievance review. Ask our Customer Service Department to provide you with a FHS-HMO "Formal Grievance Form". If necessary, a Customer Service Representative will assist you with preparing your grievance. You may file a Grievance or Complaint one of three ways:Level 2-Formal Grievance
If you disagree with the outcome of the Level-1 review of an informal grievance, FHS-HMO provides members with an optional Level-2 Formal Grievance process. Level-2 grievances may be submitted in writing, as long as it is received by FHS-HMO within 30 days of your receipt of the Level-1 determination. You may also file your formal grievance with the Florida Agency for Health Care Administration or the Florida Department of Financial Services. Please be sure to include all additional information and copies of pertinent documentation such as your medical records.
If your grievance is due to an adverse determination and denied, you also have the right to request a Level-2 formal grievance within 30 days of the determination. An adverse determination is a determination by us that an admission, availability of care, continued stay, or other health care service was reviewed and, based upon the information provided, is not a covered benefit under your plan. Coverage for the requested service is therefore denied, reduced or terminated.
All formal grievances will be acknowledged by FHS-HMO within five (5) business days of receipt. You will receive written notification from FHS-HMO of the grievance outcome once a determination has been made, or within thirty (30) business days from the date of receipt. If your grievance involves activities which occurred outside the service area, or requires the collection of information from outside the service area, FHS-HMO shall have an additional thirty (30) days in addition to each of the response/notice periods set forth above, to process your grievance.
If you disagree with our Level-2 determination, you may request either verbally or in writing a review by the FHS-HMO Grievance Review Panel ("the Panel"). For adverse determinations, the majority of the Panel will be persons who have the appropriate expertise, and who were not involved in the initial adverse determination. A person who was previously involved in the adverse determination may appear before the Panel to present information or answer questions. Each party related to the grievance has the right to appear in person to present arguments. The Panel will issue a final decision to the Subscriber, and provider if any, who files on behalf of the Subscriber, within thirty (30) business days of a request for a Panel review. All grievances will be finalized within sixty (60) days of receipt of the formal grievance, unless thirty (30) additional days are needed to collect information outside theFHS-HMOservice area.Expedited (Urgent) Grievance Review In all cases where the standard 30-day grievance review time frame would jeopardize your life, health, or ability to regain maximum function, you, your legal representative, or physician authorized to act on your behalf (who is directly involved in your treatment or diagnosis) may file a request for an expedited (urgent) grievance review. You may request this review either verbally or in writing by contacting FHS-HMO as specified above. This process only applies to a pre-service or concurrent, and not retrospective, denial. For example, this does not apply to a request for payment of services already rendered but denied, other claims review, or reimbursement. If the expedited review process does not resolve a difference of opinion between FHS-HMO and the Member or the provider acting on behalf of the Member, the Member or provider may submit a written grievance to the Subscriber Assistance Program.
FHS-HMO will, after review and validation of your request, expedite the grievance procedure, and render a determination within seventy-two (72) hours of receipt of your request. This review will be conducted by appropriate clinical peers who were not involved in the initial determination within twenty-four (24) hours after receiving a request for an expedited appeal. We will decide within seventy-two (72) hours and notify you of our decision. Any verbal notice will be followed with written notice within two (2) working days.Level 3-State Appeals
If you do not accept the decision of the Panel, you have the right to appeal to the Florida Agency for Health Care Administration (AHCA) or the Department of Financial Services (FDFS) within one (1) year from the date of receipt of our decision. If you appealFHS-HMO's decision, your grievance will be reviewed by the Subscriber Assistance Program. You also have the right to contact AHCA or DFS at any time to inform them of an unresolved grievance.
The Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire FHS-HMO Grievance process, nor if the Member has instituted an action pending in the state or federal court.
Pursuant to Florida law, FHS-HMO may not provide information to you concerning the outcome of quality of care complaints. If you need further assistance, you may contact:
The Florida Agency for Health Care Administration and the Subscriber Assistance Program
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephones 1-888-419-3456 and 1-850-921-5458
The Florida Department of Financial Services
Division of Consumer Services
200 East Gaines Street