Submission of Formal Grievances and Appeals: to simply health care insurance

Providers are encouraged to first communicate any concerns or dissatisfaction about an SHP process or decision verbally through the Provider Relations telephone lines at 1-800-887-6888 ext. 6005 Monday through Friday between 8 AM and 7 PM EST, excluding state holidays. After hours, an electronic voice messaging system will record provider complaints.

1. All SHP providers have the right to submit a formal written appeal to SHP:

* within 45 calendar days from the denial disposition on a referral/authorizations/grievance
adverse determination;

* within 365 calendar days from the date of service for a claim adverse decision

2. A provider’s written grievance and/or appeal must be forwarded to the SHP Provider Appeals
Coordinator at the following address:

Simply Healthcare Plans, Inc.
1701 Ponce De Leon Blvd, Suite 300
Coral Gables, Fl 33134-4414
Toll Free Number: 1-800-213-1133
Attn: Provider Appeals Coordinator

3. Provider grievances and appeals are handled by the Provider Appeals Coordinator and are reviewed with the corresponding and designated department head.

4. All provider complaints are investigated using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Plan’s written policies and procedures.

5. SHP’s Director of Provider Relations, and the Chief Operating Officer and/or Chief Medical  Officer if appropriate, are involved in the provider complaint process, and have authority to require corrective action plans.

6. Upon the receipt of the provider grievance/appeal letter, a provider grievance acknowledgement letter will be forwarded to the provider within five (5) working days from the receipt of the document.

7. A resolution to the provider’s appeal will be rendered and communicated to the provider in writing within a sixty (60)-day period from the receipt of the provider appeal or grievance. The letter will include information on filing a Level II appeal, should the provider not be satisfied with the decision.

8. Grievance extensions: If the review of the grievance (excluding appeals) involves the collection of
information outside the service area or from a non-participating provider, an additional 30 days extension is allowed, with prior notification to the provider.

9. The time limitations requiring completion of the grievance review shall be tolled after SHP has notified the provider in writing that additional information is required. Upon the receipt of the additional information required, the time frame for completion of the grievance process shall resume.

10. For appeals/grievances requiring a re-review of clinical records, a Medical Director or consultant other than the one who made the initial review will process the appeal and corresponding documents and render a determination.

11. The provider may request a Second Level Appeal, which includes a Grievance Committee Hearing. The provider has 10 (ten) working days from the receipt of the initial grievance/appeal determination to request a Grievance Committee Hearing. Such request will be acknowledged by the Plan within 5 (five) working days.

12. The Plan will advise the provider in writing of the date, time, and place of the Grievance Committee meeting. The Committee includes SHP-credentialed providers not involved with the
original adverse determination. All documentation must be gathered and presented to the Committee within sixty (60) calendar days from the request for the second appeal.

13. The provider has the right to be represented by an attorney or other person of their choice. The provider needs to notify SHP of such representation at least ten (10) working days prior to the scheduled hearing. SHP may in those cases have legal representation present.

14. SHP will send the provider a disposition letter within ten (10) working days from the date of the Committee meeting, and never to exceed 60 calendar days from the request for a Grievance Committee Hearing.

15. The review process at all levels includes SHP’s Clinical Guidelines that incorporate the Florida Medicaid Program Guidelines.

16. There is no further appeal for the decision of the second level appeal.

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