APPEAL AND GRIEVANCE PROCEDURE

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.

MEMBER APPEALS OF ADVERSE DETERMINATIONS


II. INTERNAL APPEAL OF ADVERSE BENEFIT DETERMINATIONS: