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Children’s Medical Services (CMS) Plan by Molina Healthcare will be here to support you and help resolve any concerns you may have.

A grievance is when you let us know you are unhappy with something that is not related to a decision about your child’s care. An appeal is when you ask us to review a decision we made about your child’s care. This type of decision is called a Notice of Adverse Benefits Determination (NABD). Your CMS Plan Member Handbook will include more information about the Complaints, Grievances and Appeals process.

It will be important that you let us know right away about any problems. This includes if you do not agree with a decision we have made.

Filing a Complaint

If you are not happy with us or providers, you will be able to file a complaint. You may call us at any time at (800) 262-0750 (TTY: 711). We will try to solve your issue within one business day.

Filing a Grievance

If you are not happy with us or providers, a grievance will be filed. You will able to write us or call us at any time at (800) 262-0750 (TTY:711). You will also be able to call us to ask for more time to solve the grievance if more time could help. You will contact us at:

We will send you a letter acknowledging receipt of your grievance. The grievance will be reviewed and a letter sent with our decision within 30 days. If we need more time to solve a grievance, we will send a letter with our reason and explain the next steps if you disagree.

Filing an Appeal

If you do not agree with a decision we make about the services, you will be able to request an appeal. You will write us, or call us and follow up in writing, within 60 days of our decision about your child’s services at (800) 262-0750 (TTY: 711). You will be able to ask for your child’s services to continue within 10 days of receiving our letter, if needed. Some rules may apply. Submit additional information during the appeal process; time will be limited to submit additional information on an expedited appeal. You will contact us at:

We will send a letter within five business days to confirm we received the appeal. We are happy to help you complete any forms. The CMS plan will review the appeal and send an answer in a letter within 30 days.

Filing an Expedited or "Fast" Appeal

You or your representative can request an expedited appeal verbally or in writing.

Expedited or “fast” appeals will be considered when your child is currently receiving treatment, and your medical provider believes a delay in treatment could seriously jeopardize your child's life or overall health, affect your child’s ability to regain maximum functions, or subject your child to severe and intolerable pain. (Your child has a life- or limb-threatening condition.) The issue will likely be related to an admission or continued inpatient stay and your child has not yet been discharged. You will write us or call us within 60 days of our decision about the services. You will contact us at:

We will give you an answer within 48 hours after we received your request. We may 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.

Continuation of Benefits for Medicaid Members

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

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

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

To have your child's services continue during your appeal or fair hearing, you will be able to 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 child's services will be reduced, suspended or terminated.

Medicaid Fair Hearings

A parent, guardian or member may request a Medicaid fair hearing at any time up to 120 days after receiving a Notice of Plan Appeal Resolution by calling or writing to:

If a fair hearing is requested in writing, you will need to include the following information:

• Your name
• Your child’s member number
• Your child’s 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 a 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 or KidCare (Titel 21) member, you are not allowed to have a Medicaid Fair Hearing.

External Review for KidCare (Title 21)

If you are a KidCare (Title 21) member and you do not agree with our Plan Appeal decision, you will have the right to request an independent external review by an Independent Review Organization (IRO). An IRO is an independent organization that is not connected to CMS. The IRO will review your child’s case and make a final decision.

You must request the external review within the timeframe listed in your Notice of Plan Appeal Resolution letter. To request an external review, follow the instructions included in your appeal resolution letter or contact us at:

If your child’s services continue during the appeal process and you request an external review within the required timeframe, services may continue until the external review decision is made. Some rules may apply. The decision made by the Independent Review Organization is final.

Children’s Medical Services (CMS) Plan by Molina Healthcare will provide managed care services to our members. Molina Healthcare is a licensed Florida health plan. CMS Plan will provide free aids and services to people with disabilities, such as qualified sign language interpreters, written information in other formats (large print, audio, accessible electronic and other formats), and free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. This information will be available for free in other languages. Please contact Member Services at (800) 262-0750 (TTY: 711) Monday - Friday, 8:00 a.m. to 7:00 p.m.