Complaints, Grievances and Plan Appeals (KidCare)
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 providers or us, 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.
External Review
If you do not agree with our appeal decision, you can ask for an External Review.*
What to Do
- You can submit the Notice of Plan Appeal Resolution to us within 120 calendar days of the date of the Notice
*You must finish the appeal process before you can have an External Review.
What We'll Do
- Restart your services if the External Review Organization agrees with you.
A parent, guardian or member may request an External Review at any time up to 120 days after receiving a Notice of Plan Appeal Resolution by calling or writing to:
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
If an External Review is requested in writing, please include the following information:
- Your child’s name
- Your child’s member number
- Your child’s KidCare 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 External Review
After getting your External Review request, the External Review Organization will tell you in writing that they got your request.