Medicare Advantage

Medical Authorizations, Appeals and Grievances (2014)

Covered medical services and prior authorizations

Q1: How do I know what medical services are covered, and which ones require authorization?
A1: Your Evidence of Coverage will list the services that are covered and indicate which services require prior authorization.

Q2: How do I get prior authorization for a medical service?
A2: Your doctor will typically send us a request, including any clinical information to support it, or you can use the form below. Simply complete the form and submit it to us according to the instructions on the form.

Q3: How do I know what services are not covered ?
A3: Your Evidence of Coverage will list the services that are not covered (exclusions). 

Q4: What should be included with the authorization request?
A4: A physician's statement indicating why the medical service is medically necessary, in addition to clinical documentation supporting the request.

Q5: If I request an authorization with all the required information, will it be approved?
A5: Not necessarily. It will be reviewed by a Medical Director, and a decision will be based on clinical evidence and your unique medical condition.

Q6: How long will it take to get a decision on my authorization request?
A6: A decision will be made as soon as required for your medical condition but no later than 14 days for complete standard requests, and 72 hours (3 days) if the standard timeframe could jeopardize your health. Your doctor should indicate if the fast timeframe is warranted, and the decision will be made in 72 hours. Contact customer service to find out the status of your request.

Q7: How will I know about the plan's decision on my authorization request?
A7: If the authorization is approved, you and your doctor will receive an approval letter indicating the authorization number and length of coverage. If the request is denied, you and your doctor will receive a denial letter indicating the reason for the decision and how to appeal it if you choose.

Q8: If my request is approved, what will my cost-share be?
A8: If an authorization for medical services is approved, you will be responsible for the cost-share for the requested service as listed in your Evidence of Coverage.

Appeals

Q9: If my request is denied, how can I appeal?
A9: If your request for coverage of medical care is denied, you or your authorized representative can file an appeal by writing to us within 60 days from the denial, telling us why you believe the decision was incorrect. If the situation is urgent and you need a decision quickly, your doctor will automatically be considered your authorized representative and can appeal on your behalf. Expedited appeals will be accepted in writing, or verbally by contacting customer service. If the appeal is not urgent, you can file a written appeal, or authorize someone to act on your behalf in writing, or call us at 1-855-882-6467 weekdays from 8 am to 8 pm and Saturday from 8 am to noon, or though TDD/TTY Relay at (800) 955-8771. Pre-service appeals will be decided within 30 days unless your medical condition warrants an expedited timeframe, in which the appeal will be decided within 72 hours. We may make a 14 day extension if we need time to gather information that benefits you. Appeals for services that have already been received will be decided within 60 days. You will have the right to an external review if the decision is still not in your favor.

Grievances

Q10: What can I do if I have a complaint about something other than coverage for a medical service I requested?
A10: If you are dissatisfied with any aspect of your plan, including a decision not to expedite a coverage decision for you, you can file a grievance within 60 days of the incident. We hope that you will call us first about your concern, but if we cannot resolve it for you immediately, you can also send a written grievance along with supporting information to:

Health First Health Plans
Attn: Member Advocate
6450 US Highway 1
Rockledge, FL 32955

To contact us by phone, please call 1-855-882-6467 weekdays from 8 am to 8 pm and Saturday from 8 am to noon. TDD/TTY Relay users can also contact us at (800) 955-8771 during the same hours.

Q11: What happens after I file a grievance?
A11: Appropriate people at Health First Health Plans will investigate your concern and advise you of the outcome of the review within 30 days, unless a 14-day extension is warranted. Your satisfaction is our greatest concern and we will do everything possible to ensure you are treated fairly.

Q12: What if my grievance is related to the quality of care I received?
A12: You can file a grievance with Health First Health Plans as described above, and can also file your grievance with the Florida Quality Improvement Organizations (QIO) by contacting them at:

Florida Medical Quality Assurance, Inc.
5201 W. Kennedy Boulevard, Suite #900
Tampa, FL 33609

Phone: (813) 354-9111

How to contact Medicare

Our Customer Service Representatives are dedicated to personally solving any problems you may have with us and our providers to your full satisfaction. If you prefer to contact the Centers for Medicare and Medicaid Services (CMS) directly, please visit Medicare's web site:


Y0089_MP3536FH Approved 11/06/2013
Last updated: 10/01/2013