This section describes your rights to request coverage of medical care or services or payment for medical services that you already have received. You also may make a complaint about your medical benefits and coverage.
To learn about your rights to make complaints about your prescription drug benefits and coverage, please go to this section of the site. To learn more about your prescription drug benefits and coverage, please review Medicare-Approved Prescription Drug Coverage.
Chapter 9 of your 2010 Evidence of Coverage (pdf 3.22 MB) explains the medical grievance and appeals rights and procedures in more detail.
Whenever you ask for coverage of a medical service or payment for a medical service that you have received, the first step is called requesting an "organization determination." An organization determination is CHP's initial decision about whether we will provide the medical care or service that you request, or pay for a service that you have received. If our initial decision is to deny your request, you can appeal the decision by going to Appeal Level I (below).
You have the right to make a complaint if you have concerns or problems about your medical care or coverage. "Appeals" and "grievances" are the two different types of complaints that you can make.
An "appeal" is the type of complaint that you make when you want CHP to reconsider and change a decision that we have made about what medical services or benefits are covered for you or what we will pay for a service or benefit. For example, if we will not cover or pay for services that you think we should cover, you can file an appeal. If you think that we are stopping the coverage of a medical service or benefit too soon, you can file an appeal.
A "grievance" is the type of complaint that you make if you have any other type of problem with CHP or one of our plan providers. For example, you would file a grievance if you have a problem such as the quality of your care, waiting times for appointments, the way your doctors or others behave, or the cleanliness or condition of a doctor's office.
Your doctor or other medical provider may ask us whether we will approve medical services or treatment. You also can ask us for an initial decision, or you can name (appoint) someone to do it for you. If you want someone to act for you, you and the person you want to act for you must sign and date a statement that gives this person legal permission to be your representative. Please use the Appointment of Representative form [PDF]. (pdf 222.04 kB)
A decision about whether we will pay for or approve medical care can be a "standard decision" that is made within the standard timeframe, or it can be a "fast decision" that is made more quickly. You can ask for a fast decision only if you or any doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.
To ask for an organization decision, you or your doctor may call CHP Member Services at the number listed below. You also may fax, mail, or deliver a written request for services. Be sure to ask for a "fast" or "72-hour" decision if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function.
Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317-5349
Deliver:
Capital Health Plan
Member Services
1545 Raymond Diehl Road, Suite 300
Tallahassee, FL 32308
Telephone:
850-523-7441 (1-877-247-6512 toll-free) (TTY 850-383-3534 or 1-800-955-8771 toll-free)
Fax:
850-383-3413
CHP will review your request and make an organization determination within the following timeframes:
If we deny your request, we will send you a written decision explaining the reason(s). If we deny all or any part of your request in our organization determination, you may ask us to reconsider our decision. This is called an "appeal" or "request for reconsideration." Please call us at 850-523-7441 (1-877-247-6512 toll-free), (TTY 850-383-3534 or 1-800-955-8771 toll-free) 8 a.m. to 8 p.m. if you need help filing your appeal. You must appeal our denial within 60 calendar days of the date on the notice of our organization determination. (We can give you more time if you have a good reason for missing the deadline.)
Standard Request for Service (30 days) - You can ask for a standard appeal requesting that we authorize or approve a service that you have not yet received. We must give you a decision no later than 30 days after we get your appeal. (We may extend this time by up to 14 days if you request an extension or if we need additional information and the extension benefits you.)
Standard Request for Payment (60 days) - You can ask for a standard appeal requesting payment for a service you have already received. We must give you a decision no later than 60 days after we get your appeal.
Fast (72-hour review) - You can ask for a fast appeal if you or your doctor believe that your health could be seriously harmed by waiting too long for a decision. We must decide on a fast appeal no later than 72 hours after we get your appeal. (We may extend this time by up to 14 days if you request an extension or if we need additional information and the extension benefits you.)
You should include your name, address, member ID number, reasons for appealing, and any evidence that you wish to attach. You may include supporting medical records, doctors' letters, or other information that explains why we should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.
For a Standard Appeal: You, your doctor, or your appointed representative [PDF] (pdf 222.04 kB) should mail or deliver your written appeal to the addresses below:
Mail:
Capital Health Plan
Attention: Grievances/Appeals
P.O. Box 15349
Tallahassee, FL 32317-5349
Deliver:
Capital Health Plan
Member Services
1545 Raymond Diehl Road, Suite 300
Tallahassee, FL 32308
For a Fast Appeal: You, your doctor, or your appointed representative [PDF] (pdf 222.04 kB) should contact us by telephone or fax:
Telephone:
850-523-7441 (1-877-247-6512 toll-free) (TTY 850-383-3534 or 1-800-955-8771 toll-free)
Fax:
850-383-3413
If you appeal, we will review our decision. If we continue to deny any of the services that you requested, Medicare will provide you with a new and impartial review of your case by a reviewer outside of CHP. If you disagree with the decision of the outside reviewer, you will have further appeal rights. You will be notified of those appeal rights if this happens.
Fast (24 hours) - If you disagree with our decision not to give you a fast decision on medical care, or if you disagree with our decision to take a time extension on initial decisions or appeals. We must respond to this type of grievance within 24 hours of the time that we receive it.
Standard (30 days) - Any other type of complaint. We must respond to this type of grievance as promptly as your medical condition requires, but no later than 30 calendar days of the date that we receive it.
If you are concerned about the quality of care that you received, you also can submit a written complaint to the following independent organization:
Florida Medical Quality Assurance, Inc.
5201 W. Kennedy Blvd., Ste. 900
Tampa, FL 33609-1822
Telephone: 1-813-354-9111
Toll-Free: 1-800-844-0795
You or your appointed representative (pdf 222.04 kB) may call Member Services or you may write to us. If you submit a written grievance, you will get an answer in writing. If you submit a verbal grievance, you will get an answer by telephone, unless you ask for an answer in writing. All quality of care grievances will be answered in writing.
For an Expedited Grievance: You or your appointed representative [PDF] (pdf 222.04 kB) should call, mail, or deliver your grievance request to the address/number below:
Telephone:
850-523-7441 (1-877-247-6512 toll-free) (TTY 850-383-3534 or 1-800-955-8771 toll-free)
Fax:
850-383-3413
For a Standard Grievance: You or your appointed representative [PDF] (pdf 222.04 kB) should call, mail, or deliver your grievance request to the address/number below:
Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317
Deliver:
Capital Health Plan
Member Services
1545 Raymond Diehl Road, Suite 300
Tallahassee, FL 32308
Telephone:
850-523-7441 (1-877-247-6512 toll-free) (TTY 850-383-3534 or 1-800-955-8771 toll-free)
If you need information or help, or would like to obtain an aggregate number of grievances, appeals, and exceptions filed with this plan, call us at:
850-523-7441
877-247-6512 (toll-free)
850-383-3534 (TTY/TDD)
800-955-8771 (TTY/TDD toll-free)
Seven days a week, 8 a.m. to 8 p.m.
Medicare Rights Center: 1-888-HMO-9050 (toll-free)
Elder Care Locator: 1-800-677-1116 (toll-free)
1-800-Medicare (1-800-633-4227)
TTY/TDD 1-877-486-2048
24 hours a day, 7 days a week
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