• Overview
• Grievances (Complaints)
  • Making a Complaint
• Problems/Concerns about Part C Medical Benefits and Coverage
  • Coverage Decisions
  • Appeal a Coverage Decision
• Problems/Concerns about the Part D Prescription Drug Benefit
  • Coverage Decision/Exceptions
  • Appeal a Coverage Decision

MAKING A COMPLAINT

• Usually calling Member Services is the first step - If there is anything else you need to do Member Services will let you know. Call 1-877-615-4022. Hearing Impaired call TRS Relay 711. Hours of operation are 7 days a week, 8 a.m. to 8 p.m.
• If you do not wish to call (or you called and were unsatisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances. Here's how it works:
  • You may send you written complaint via mail, fax or e-mail to FHCP's Member Services Department:

Florida Health Care Plans
Attn: Member Services
1340 Ridgewood Avenue
Holly Hill, FL 32117
Fax#: 386-676-7149
E-mail: Member Services click here

If you need assistance in preparing a written grievance, a Member Services Representative will work with you and will forward you a copy of the written document when completed for your signature, along with a self-addressed stamped envelope for returning the document to FHCP.

Once we receive your complaint we will work with the appropriate administrative personnel and departments to review your concerns. We will complete this review process within 30 days from receipt of your complaint. We may extend this time by an additional 14 days if we require additional information. If additional time is necessary we will notify you of the need and the reason for the additional time within the first 30 days. At the end of our investigation you will be notified, verbally of the outcome by one of our Member Service Representatives.

If your complaint was received by Member Services in writing (this is also called a Greivance), or, if your complaint is regarding quality of care, then you will receive both a verbal and written notification of the outcome of our investigation.

Complaints received in writing may be reviewed by our Medical Review/Benefits Review Panel this Panel consists of Licensed Professional and Physician Reviewers whose expertise is directly related to the type of complaint made.

If you need assistance in preparing a written complaint (this is also called a Grievance), a Member Services Representative will work with you and will forward a copy of the written document when completed, for your signature, along with a stamped self-addressed envelope for returning the signed document to us.

If you or your representative has a complaint regarding a quality issue you, your authorized representative, or a physician you have authorized to act on your behalf may contact the state's Quality Improvement Organization (QIO) in Florida the quality improvement organization is listed below:

Florida Medical Quality Assurance, Inc.
5201 West Kennedy Blvd
Suite 900
Tampa, FL 33609-0795
Phone: 1-813-354-9111
TTY Users: TRS Relay 711

"FAST" Complaint

If you are making a complaint regarding our decision to extend the timeframe by 14 days of a request for medical care or an appeal regarding medical care we had denied you can request a "Fast" Complaint or "Fast" Grievance.

You can also request a "Fast" Complaint or "Fast" Grievance if we have decided to deny your request for a "Fast" or "Expedited" initial determantion or appeal.

When we recieve your verbal or written request for a "Fast" Complaint we will review your concerns and respond to you both verbally and in writing within 24 hours.

"Urgent" Complaint

If you are concerned about the quality of care you are receiving or have received, or if you have a complaint such as a delay in access to service and believe that it is a medically necessary that we resolve your complaint as fast as possible, you can request an "Urgent" review.

• Your request for an "Urgent" Complaint may be made by phone, in writing, by faxing, or by e-mail to our Member Services. Once our Member Services receives your request for an "Urgent" Complaint we will review your concerns with the appropriate Administration, Departments, and/or Medical Review Panel. We will notify you both verbally and in writing of the results of our review within 72 hours. We may extend this time by an additional 14 days if we require additional information. If additionl time is necessary we will notify you of the need and the reaason for the additional time within the first 72 hours.
• Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
• If you are making a complaint because we denied your request for a "fast response" to a coverage decision or appeal, we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
• Members of the Medvantage Plan please refer to Chapter 7 of your Evidence of Coverage for complete information on filing a complaint (grievance).
• Members of the Medvantage Rx Plan please refer to Chapter 9 of your Evidence of Coverage for complete information on filing a complaint (grievance).
• Members of the Medvantage Rx Plus Plan please refer to Chapter 9 of your Evidence of Coverage for complete information on filing a complaint (grievance).