Medicaid Fair Hearing

The member has the right to request a Medicaid Fair Hearing in addition to pursuing Prestige Health Choice’s grievance process. If the Medicaid Fair Hearing Process is chosen, the member waives his/her further rights to appeal to the Beneficiary Assistance Program. The provider, acting on behalf of the member and with the member’s written consent, may also request a Medicaid Fair Hearing.

Parties to the Medicaid Fair Hearing are Prestige Health Choice staff, the member and his/her representative or the representative of a deceased member’s estate and state staff. The member, the representative or provider may only request a Medicaid Fair Hearing within 90 days of the date of the notice
of action and/or denial. The request must be sent to DCF at the following address:
Office of Public Assistance Appeals Hearings 1317 Winewood Boulevard

Building 1, Room 309
Tallahassee, FL 32399-0700

Prestige Health Choice will continue the member’s benefits while the Medicaid Fair Hearing is pending if:

1. The Medicaid Fair Hearing is filed timely, meaning on or before the latter of the following:
a. Within 10 calendar days of the date on the notice of action
(add five calendar days if the notice is sent via U.S. mail).
b. The intended effective date of Prestige Health Choice’s proposed action.
2. The Medicaid Fair Hearing involves the termination, suspension or reduction of a previously authorized course of treatment;
3. The services were ordered by an authorized provider;
4. The authorization period has not expired; and
5. The member requests extension of benefits.

If Prestige Health Choice continues or reinstates the member’s benefits while the Medicaid Fair Hearing is pending, the benefits will be continued until one of following occurs:
1. The member withdraws the request for Medicaid Fair Hearing.
2. Ten days pass from the date of Prestige Health Choice’s adverse plan decision and the member has not requested a Medicaid Fair Hearing with continuation of benefits until a Medicaid Fair Hearing decision is reached (add five days if the notice is sent via U.S. mail).
3. A Medicaid fair hearing decision adverse to the member is made.
4. The authorization expires or authorized service limits are met.

Prestige Health Choice will authorize or provide the disputed services promptly, and as expeditiously as the member’s health condition requires, if the services were not furnished while the Medicaid Fair Hearing was pending and the Medicaid Fair Hearing officer reverses a decision to deny, limit, or delay services.
Prestige Health Choice will pay for disputed services, in accordance with state policy and regulations, if the services were furnished while the Medicaid Fair Hearing was pending and the Medicaid Fair Hearing officer reverses a decision to deny, limit, or delay services. Prestige Health Choice will not take punitive action against a provider who requests a Medicaid Fair Hearing on the member’s behalf or supports a member’s request.

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