Are you having problems with your medical care or our services? If so, you have a right to file a grievance or appeal.

A grievance can be filed when you are unhappy with your care.

• The care you get from your provider;
• The time it takes to get an appointment or be seen by a provider or;
• The providers you can choose for care.

• Stop, suspend, reduce or deny a service or;
• Deny payment for services provided.

You may ask for a Medicaid Fair Hearing through the Department of Children and Families. To request a Medicaid Fair Hearing call 1-850-488-1429.

You also have the right to request a Subscriber Assistance Program (SAP) hearing. To request a SAP hearing call 1-888-419-3456. If you have a SAP hearing you may not request a Medicaid Fair Hearing.

Grievance and Appeals Form

How to file a Grievance

• Call the Member Services Department at 1-866-472-4585.
• Fill out the Grievance/Appeal form. It is in your Member Handbook.
• Call the Member Services Department. Ask them to mail you a form.
• Write a letter.
• Call Member Services to help you write your grievance.

• Your first and last name
• Your Molina ID number. It is on the front of your member ID card.
• Your address and telephone number.
• Explain the problem.

Molina Healthcare of Florida
P.O. BOX 521838
Miami, FL 33152-1838
866-472-4585 

• Someone has the wrong information
• Someone misunderstood
• Someone needs more information

If you wish, you can write to us. You or a representative can talk to the people reviewing your grievance. You can do this in person. You can present your case on the phone. Tell us you want to do this when you write. We will call you and set up the meeting.

How to appeal a denial

YOU HAVE A RIGHT TO APPEAL A DENIAL

What is a denial? A denial means Molina Healthcare is telling a provider and you that services or bills will not be paid. If we deny your service or claim, you have the right to request why your services or bills were denied. You have a right to appeal.

If your service or claim is denied, you will get a letter called a notice of action from Molina Healthcare telling you about this decision. This letter will tell you about your right to appeal. You can read about these rights in your Member Handbook.

Member Services also can help you file an appeal. If you are not happy with the result of your appeal, you can ask for an independent review. This means providers outside Molina Healthcare review all the facts in your case and make a decision. We will accept that finding.

Would you like to ask for a review of an appeal? Call Member Services and ask them to help set this up for you.

How to File a Medicaid Fair Hearing

You have the right to ask for a Medicaid Fair Hearing. You can do this at anytime during the appeal or grievance. Someone can call for you. It can be someone you say can act for you. It can also be a Provider acting for you. You must write a note that gives permission.

Office of Appeals Hearings
1317 Winewood Blvd.
Bldg. 5 – Room 203
Tallahassee, FL 32399-0700
1-850-488-1429

You must request this hearing in (90) days or less. This from the date you first got the initial decision. Someone can call for you. You can have someone act for you. A Provider can act for you. You must write a note that gives permission. If you choose this service, you give up the right to the review by the Subscriber Assistance Program.

This is what happens when you ask for a Medicaid Fair Hearing. You get a letter from the hearing officer. The letter will tell you the date and time of the hearing. The letter tells you how to get ready for the hearing. The hearing can be held by telephone. You can explain why you asked for this service. You can ask the hearing officer to look at the case and make a decision.

The Office of Appeals will give you a final decision. This happens in (90) days or less from the date you asked for the hearing.

Subscriber Assistance Program (SAP)

You can ask for a hearing from the SAP. This is in case you are not satisfied with the appeal decision. You can do this anytime during the appeal. You can also do this any time during a grievance. You have one (1) year from the time of denial to submit to SAP for review. The SAP will not consider a Grievance or Appeal taken to a Medicaid Fair Hearing. The SAP only hears certain kinds of cases.

• If you are able to get health care services.
• The benefits that are covered.
• An action or denial we made.
• A benefit action/denial made by us.
• Payment of a claim.
• The way we handle a claim.
• Paying you back for benefits.

To request a hearing contact the SAP at:

2727 Mah Dr., Fort Know #1 Mail Stop 26
Tallahassee, FL 32308
850-412-4502
850-413-0900 Fax
sap@ahca.myflorida.com

If you have a SAP hearing you may not request a Medicaid Fair Hearing.

How to File an Expedited Appeal

An expedited appeal means the decision is made right away. You can ask for this kind of appeal. Ask for an expedited appeal if the regular wait time would risk your life or health. You can call a Member Services and ask to file an expedited appeal. We will help you.

Molina makes a decision on an expedited appeal in (72) hours. It can be up to (14) days more. This is if we need more information. Sometimes it is better for you this way. We will call you if we need more time. We will send a letter in two (2) working days or less. There may be a risk to your life. A decision will be made within (24) hours. This is from the time we get your expedited appeal.

Molina may decide that your appeal should not be expedited. Then we will follow the standard appeal process. We will call you as soon as this is decided. We will, we will try to call you to let you know the standard appeal process will be followed. We will also send you a letter in two (2) days or less.

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