Reso 2010-1529 - Laserfiche WebLink

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1 If a Member has a complaint involving a Claim for benefits, including a benefit denial, he or she may file a written appeal with AvMed. The procedures for filing an appeal are described below, beginning with Section 16.D2. ) 16.01 Grievances relating to plan services: 16.01.01 If a Member's complaint cannot be resolved informally over the telephone, the cornplaint may be subrnitted in writing to AvMed's Member Services Department. We call this 'filing a grievance'. Grievances must be filed within one year of the occurrence of the event or action that led to the grievance. We will acknowledge and investigate the grievance, and provide a written response advising of the disposition of the grievance within 60 days after receipt of the written grievance. You may submit a grievance in writing to; AvMed Member Services - North AvMed Member Services - South P.O. Box 823 P.O. Box 569008 Gainesville, Florida 32602-0823 Miami, Florida 33156-9906 Telephone: 1-800-882-8633 Telephone: 1-800-882-8633 Fax: (352) 337-8612 Fax: (305) 671-4736 .) 16.01.02 If you are not satisfied with AvMed's final decision, you may contact the Agency for Health Care Administration (AHCA) or the Department of Financial Services (DFS) in writing within 365 days ofreceipt of AvMed's fmal decision letter. If you appeal AvMed's decision, your grievance will be reviewed by the Subscriber Assistance Program. You also have the right to contact AHCA or DFS at any time to inform them of an, unresolved grievance. a) The Subscriber Assistance Program will not hear a grievance if you have not cornpleted the entire AvMed grievance process nor if you have instituted an action pending in State or Federal court. If you need further assistance, you may contact; Subscriber Assistance Program (SAP) Florida Department of Financial Services Agency for Health Care Adrninistration 200 East Gaines Street HMO Section Tallahassee, Florida 32399 2727 Mahan Drive, Mail Stop 26 Telephone 1-800-342-2762 Tallahassee, Florida 32308 Telephone 1-888-419-3456, or 850-921-5458 ) 16.02 Pre-Service Claims. 16.02.01 Initial Claim. A Pre-Service Claim shall be deemed to be filed on the date received by AvMed. AvMed shall notifY the Claimant of the benefit de!ermination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after AvMed receives the Pre-Service Claim. AvMed may extend this period one time for up to 15 days, provided that AvMed determines that such an extension is necessary due to matters beyond AvMed's control and notifies the Claimant, before the expiration of the initial 15-day period, of the circumstances requiring the extension of time and the date by which AvMed expects to render a decision. If such an extension is necessary because the Claimant failed to submit the information necessary to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days frorn receipt of the notice within which to provide the specified information. In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre-Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed in filing a Claim for benefits not later than 5 days following such failure. AvMed's period for making the benefit determination shall be tolled from the date on 39 A V-GlOO.2009 MP-5319 (10/09)