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Complaints, Grievances and Plan Appeals

Sunshine Health wants to fully solve your 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).

Filing a Complaint

If you are not happy with us or our providers, you can file a Complaint.

What You Can Do

Call us at any time. 1-866-796-0530 (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 our providers, you can file a Grievance.

What You Can Do

Write us or call us at any time. 1-866-796-0530 (phone) or TTY at 1-800-955-8770. Call us to ask for more time to solve your grievance if you think more time will help.

You can contact us at: 

Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Fax: 1-866-534-5972
Email: Sunshine_Appeals@centene.com

What We'll Do

  • Review your grievance and send you a letter with our decision within 90 days unless clinically urgent and a response will be received within 72 hours.
  • If we need more time to solve your grievance, we will:
    • Send you a letter with our reason and tell you about your rights if you disagree.

Filing an Appeal

If you do not agree with a decision we made about your services, you can ask for an Appeal.

What You Can Do

  • Write us, or call us and follow up in writing, within 60 days of our decision about your services. 1-866-796-0530 (phone) or TTY at 1-800-955-8770.

You can contact us at:

Sunshine Health
P.O. Box 459087
Fort Lauderdale, FL 33345-9087
Phone: 1-866-796-0530 (TTY 1-800-955-8770)
Fax: 1-866-534-5972

Email: Sunshine_Appeals@centene.com

What We'll Do

  • Send you a letter within five business days to tell you we received your appeal.
  • Help you complete any forms.
  • Review your appeal and send you a letter within 30 days to answer you.

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:

  • You are currently receiving treatment and your medical provider believes a delay in treatment could seriously jeopardize your life or overall health, affect your ability to regain maximum functions, or subject you to severe and intolerable pain. (You have a life- or limb-threatening condition.)
  • Your issue is related to an admission or continued inpatient stay and you have not yet been discharged.

What You Can Do

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, you can ask for a Medicaid Fair Hearing.

What You Can Do

  • Write to the Agency for Health Care Administration Office of Fair Hearings.
  • Ask us for a copy of your medical record.
  • Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply.

**You must finish the appeal process before you can have a Medicaid Fair Hearing.

What We'll Do

  • Provide you with transportation to the Medicaid Fair Hearing, if needed.
  • Restart your services if the state agrees with you.

If you continued your services, we may ask you to pay for the services if the final decision is not in your favor.

Continuation of Benefits for Medicaid Members

If you are now getting a service that is going to be reduced, suspended or terminated, you have the right to keep getting those services until a final decision is made for your Plan appeal or Medicaid fair hearing.

If your services are continued, there will be no change in your services until a final decision is made.

If your 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 Medicaid benefits. We cannot ask your family or legal representative to pay for the services.

To have your 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 services will be reduced, suspended or terminated.

Medicaid Fair Hearings (for Medicaid Members)

You may ask for a fair hearing at any time up to 120 days after you get 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
1-877-254-1055 (toll-free)
1-239-338-2642 (fax)

MedicaidFairHearingUnit@ahca.myflorida.com

If you request a fair hearing in writing, please include the following information:

  • Your name
  • Your member number
  • Your 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 your 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 MediKids member, you are not allowed to have a Medicaid Fair Hearing.

Review by the State (for MediKids Members)

When you ask for a review, a hearing officer who works for the State reviews the decision made during the Plan appeal. You may ask for a review by the State any time up to 30 days after you get the notice. You must finish your appeal process first.

You may ask for a review by the State by calling or writing to:

Agency for Health Care Administration
P.O. Box 60127
Fort Myers, FL 33906
1-877-254-1055 (toll-free)
1-239-338-2642 (fax)

MedicaidHearingUnit@ahca.myflorida.com

After getting your request, the Agency will tell you in writing that they got your request.