Providers are encouraged to first communicate any concerns or dissatisfaction
about an SHP process or decision verbally through the Provider Relations
telephone lines at 1-800-887-6888 ext. 6005 Monday through Friday between 8 AM
and 7 PM EST, excluding state holidays. After hours, an electronic voice
messaging system will record provider complaints.
1. All SHP providers have the right to submit a formal written appeal to SHP:
* within 45 calendar days from the denial disposition on a
referral/authorizations/grievance
adverse determination;
* within 365 calendar days from the date of service for a claim adverse
decision
2. A provider’s written grievance and/or appeal must be forwarded to the SHP
Provider Appeals
Coordinator at the following address:
Simply Healthcare Plans, Inc.
1701 Ponce De Leon Blvd, Suite 300
Coral Gables, Fl 33134-4414
Toll Free Number: 1-800-213-1133
Attn: Provider Appeals Coordinator
3. Provider grievances and appeals are handled by the Provider Appeals
Coordinator and are reviewed with the corresponding and designated department
head.
4. All provider complaints are investigated using applicable statutory,
regulatory, contractual and provider contract provisions, collecting all
pertinent facts from all parties and applying the Plan’s written policies and
procedures.
5. SHP’s Director of Provider Relations, and the Chief Operating Officer and/or
Chief Medical Officer if appropriate, are involved in the provider
complaint process, and have authority to require corrective action plans.
6. Upon the receipt of the provider grievance/appeal letter, a provider
grievance acknowledgement letter will be forwarded to the provider within five
(5) working days from the receipt of the document.
7. A resolution to the provider’s appeal will be rendered and communicated to
the provider in writing within a sixty (60)-day period from the receipt of the
provider appeal or grievance. The letter will include information on filing a
Level II appeal, should the provider not be satisfied with the decision.
8. Grievance extensions: If the review of the grievance (excluding appeals)
involves the collection of
information outside the service area or from a non-participating provider, an
additional 30 days extension is allowed, with prior notification to the
provider.
9. The time limitations requiring completion of the grievance review shall be
tolled after SHP has notified the provider in writing that additional
information is required. Upon the receipt of the additional information
required, the time frame for completion of the grievance process shall resume.
11. The provider may request a Second Level Appeal, which includes a Grievance
Committee Hearing. The provider has 10 (ten) working days from the receipt of
the initial grievance/appeal determination to request a Grievance Committee
Hearing. Such request will be acknowledged by the Plan within 5 (five) working
days.
12. The Plan will advise the provider in writing of the date, time, and place
of the Grievance Committee meeting. The Committee includes SHP-credentialed
providers not involved with the
original adverse determination. All documentation must be gathered and
presented to the Committee within sixty (60) calendar days from the request for
the second appeal.
13. The provider has the right to be represented by an attorney or other person
of their choice. The provider needs to notify SHP of such representation at
least ten (10) working days prior to the scheduled hearing. SHP may in those
cases have legal representation present.
14. SHP will send the provider a disposition letter within ten (10) working
days from the date of the Committee meeting, and never to exceed 60 calendar
days from the request for a Grievance Committee Hearing.
15. The review process at all levels includes SHP’s Clinical Guidelines that
incorporate the Florida Medicaid Program Guidelines.
16. There is no further appeal for the decision of the second level appeal.
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