Medical Care & Services 2020

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.

Introduction

To learn about your rights to make complaints about your prescription drug benefits and coverage, visit the Prescription Drug Coverage section of our website. To learn more about your prescription drug benefits and coverage, please review Medicare-Approved Prescription Drug Coverage.

Chapter 9 of your plan’s Evidence of Coverage (EOC) explains the medical grievance, appeals rights, and procedures in more detail. To review, select your plan below:

Organization Determination

You, your authorized representative, your doctor, or another medical doctor/provider may ask us whether we will approve medical services or treatment. 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.

To ask for an organization determination, you or your doctor may call CHP Member Services, fax, mail, or deliver a written request using the contact information below. If you or your doctor believe waiting for a standard decision could seriously harm your health or your ability to function, you may ask for a "fast" or "72-hour" decision.

Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317-5349

Deliver:
Member Services - 3rd Floor
1264 Metropolitan Blvd
Tallahassee, FL, 32312

Telephone:
(850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.

Email: You can request an organization determination by emailing Member Services.

Fax:
850-383-3310

CHP will review your request and make an organization determination within the following timeframes:

For a decision about payment for services that you already have received - 30 days.
(We can take up to 30 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review.)
For a decision about services you have not received - 14 days.
(We can take up to 14 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review.)
For a "fast" decision about services you have not received - 72 hours.
(We can take up to 14 additional days if we find that some information is missing that may benefit you or if you need more time to prepare for this review.)

Appeals

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." If you need help filing your appeal, please contact us at the phone numbers listed below. 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).

There Are Three Kinds of Appeals That You Can File

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.)

If any doctor asks for a fast appeal for you, or supports you in asking for one, and the doctor indicates that waiting for 30 days could seriously harm your health, we automatically will give you a fast appeal.
If you ask for a fast appeal without support from a doctor, we will decide if your health requires a fast appeal. If we do not give you a fast appeal, we will decide your appeal within 30 days.

What Do I Include With My Appeal?

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.

How Do I File An Appeal?

For a Standard Appeal: You, your doctor, or your appointed representative (Appointment of Representative Form) should mail, fax, or deliver your written appeal.

Mail:
Capital Health Plan
Attention: Grievances/Appeals
P.O. Box 15349
Tallahassee, FL 32317-5349

Deliver:
Member Services - 3rd Floor
1264 Metropolitan Blvd
Tallahassee, FL 32312

For a Fast Appeal: You, your doctor, or your appointed representative (Appointment of Representative Form) should contact us by telephone or fax:

Fax:
850-383-3413

Email: You can request an appeal by sending a message directly to Member Services.

What Happens Next?

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.

Grievances

A "grievance" is the type of complaint that you make if you have any type of problem with CHP or one of our plan doctors and providers.

There are Two Kinds of Grievances That You Can Request

Standard (30 days) - We must respond to this type of grievance as promptly as your medical condition requires, but no later than 30 calendar days from the date we receive it.

Fast (24 hours) - This is for 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 we receive it.

Quality of Care Complaints

If you are concerned about the quality of care that you received, you can submit a written complaint to the following independent organization:

KEPRO
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609

Phone: 1-888-317-0751, Fax: 1-833-868-4058, TTY: 1-855-843-4776

How Do I Submit a Grievance?

You or your appointed representative (Appointment of Representative Form) may call CHP Member Services, fax, mail, or deliver a written grievance using the contact information below. 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.

Fax:
850-383-3413

Mail:
Capital Health Plan
Attention: Member Services
P.O. Box 15349
Tallahassee, FL 32317

Deliver:
Member Services - 3rd Floor
1264 Metropolitan Blvd
Tallahassee, FL 32312

Email: You can initiate a grievance by sending a message directly to Member Services.

Contact Information

If you need information or help, or would like to obtain an aggregate number of grievances and appeals filed with this plan, call us at: (850) 523-7441 or 1 (877) 247-6512; 8:00 a.m. – 8:00 p.m., seven days a week, October 1 – March 31; 8:00 a.m. – 8:00 p.m., Monday – Friday, April 1 – September 30. State of Florida members call 1-877-392-1532, 7:00 a.m. – 8:00 p.m.

Other Resources To Help You

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