Complaints, Grievances and Plan Appeals (Medicaid)
Children’s Medical Services Health Plan wants to fully solve all problems or concerns. A grievance is an expression of dissatisfaction about any matter other than an “action.” An appeal is a request to review a Notice of Action. For more information on the Complaints, Grievances and Appeals Process please refer to the Member Handbook (PDF).
We want you and your child to be happy with the care from providers. Let us know right away about any problems. This includes if you do not agree with a decision we have made.
Filing a Complaint
If you are not happy with us or providers, you can file a complaint.
What to Do
Call us at any time. 1-866-799-5321 (TTY 1-800-955-8770)
What We'll Do
Try to solve your issue within one business day.
Filing a Grievance
If you are not happy with us or providers, a grievance can be filed.
What You Can Do
Write us or call us at any time at 1-866-799-5321 (TTY 1-800-955-8770). Call us to ask for more time to solve the grievance if more time could help.
Contact us at:
Children’s Medical Services Health Plan
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Fax: 1-866-534-5972
Email: Sunshine_Appeals@centene.com
What We'll Do
- Send you a letter acknowledging receipt of your grievance
- Review the grievance and send a letter with our decision within 90 days. If we need more time to solve a grievance, we will:
- Send a letter with our reason and explain the next steps if you disagree.
Filing an Appeal
If you do not agree with a decision we made about the services, an appeal can be requested.
What You Can Do
- Write us, or call us and follow up in writing, within 60 days of our decision about your child’s services. 1-866-799-5321 (TTY 1-800-955-8770).
- Ask for your child’s services to continue within 10 days of receiving our letter, if needed. Some rules may apply.
- Submit additional information during the appeal process; time is limited to submit additional information on an expedited appeal.
Contact us at:
Children’s Medical Services Health Plan
Grievance and Appeals
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Phone: 1-866-799-5321 (TTY 1-800-955-8770)
Fax: 1-866-534-5972
Email: Sunshine_Appeals@centene.com
What We'll Do
- Send a letter within five business days to confirm we received the appeal.
- Help you complete any forms.
- Review the appeal and send an answer in a letter within 30 days.
Filing an Expedited or "Fast" Appeal
You or your representative can request an expedited appeal verbally or in writing.
Expedited or “fast” appeals can be considered when:
- Your child is currently receiving treatment and your medical provider believes a delay in treatment could seriously jeopardize your child's life or overall health, affect your ability to regain maximum functions, or subject you to severe and intolerable pain. (Your child has a life- or limb-threatening condition.)
- The issue is related to an admission or continued inpatient stay and you child has not yet been discharged.
What to Do
Write us or call us within 60 days of our decision about the services.
You can contact us at:
Children’s Medical Services Health Plan
Grievance and Appeals
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Phone: 1-866-799-5321 (TTY 1-800-955-8770)
Fax: 1-866-534-5972
Email: Sunshine_Appeals@centene.com
What We'll Do
- Give you an answer within 48 hours after we received your request
- Call you within 24 hours if we do not agree that you need a “fast” appeal (we will also send you a letter within two days).
- If we deny your request for a fast appeal, we will transfer your appeal into the regular appeal time frame of 30 days. If you disagree with our decision not to give you a fast appeal, you can call us to file a grievance.
Medicaid Fair Hearing
If you do not agree with our appeal decision, a Medicaid Fair Hearing* can be requested.
What to Do
- Write to the Agency for Health Care Administration Office of Fair Hearings.
- Ask us for a copy of your child’s medical record.
- Ask for medical services to continue within 10 days of receiving our letter, if needed. Some rules may apply.
*A parent, guardian or member must finish the appeal process before requesting a Medicaid Fair Hearing.
What We'll Do
- Provide you with transportation to the Medicaid Fair Hearing, if needed.
- Restart member services if the state agrees with the request for a hearing.
- Upon request, provide a parent, guardian or member a copy of the appeal file any time during and/or after the completion of the appeal review free of charge
- If services are continued, we may ask you to pay for the services if the final decision is not in your child’s favor.
Continuation of Benefits for Medicaid Members
If your child is now getting a service that is going to be reduced, suspended or terminated, your child has the right to keep getting those services until a final decision is made for your Plan appeal or Medicaid fair hearing.
If your child's services are continued, there will be no change in your child's services until a final decision is made.
If your child's services are continued and our decision is not in your favor, we may ask that you pay for the cost of those services. We will not take away your child's Medicaid benefits. We cannot ask your family or legal representative to pay for the services.
To have your child's services continue during your appeal or fair hearing, you must file your appeal and ask to continue services within this time frame, whichever is later:
- Within 10 days of the date on Notice of Adverse Benefits Determination (NABD), or
- On or before the first day that your child's services will be reduced, suspended or terminated.
Medicaid Fair Hearings (for Medicaid Members)
A parent, guardian or member may request a fair hearing at any time up to 120 days after receiving a Notice of Plan Appeal Resolution by calling or writing to:
Agency for Health Care Administration
Medicaid Fair Hearing Unit
P.O. Box 60127
Fort Myers, FL 33906
Phone: 1-877-254-1055 (toll-free)
Fax: 1-239-338-2642
MedicaidFairHearingUnit@ahca.myflorida.com
If a fair hearing is requested in writing, please include the following information:
- Your name
- Your child’s member number
- Your child’s Medicaid ID number
- A phone number where you or your representative can be reached
You may also include the following information, if you have it:
- Why you think the decision should be changed
- Any medical information to support the request
- Who you would like to help with your fair hearing
After getting a fair hearing request, the Agency will tell you in writing that they got your fair hearing request. A hearing officer who works for the state will review the decision we made.
If you are a Title XXI KidCare member, you are not allowed to have a Medicaid Fair Hearing.