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Complaints, Grievances, Appeals, and Medicaid Fair Hearings

If you are unhappy with our plan or with the care you have received from a provider or subcontractor, you can call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856) to speak with a representative. Prestige Health Choice is here to help you.

A complaint is a concern or problem you have that is related to coverage, care, or services received as a Prestige Health Choice member. If you make a complaint, Prestige Health Choice will resolve it by the end of the next business day, or else it will be moved into the grievance system by the end of the next business day.

Grievances and appeals are the two different types of complaints you can make.

Grievances

A grievance is the type of complaint you make when you’re unhappy with our plan or one of our providers. Possible subjects for grievances include:

  • Quality of care.
  • Quality of services provided.
  • Lack of respect for your rights as a member.

How to file a grievance

If you want to file a grievance, call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856), 24 hours a day, seven days a week. We will help you understand the process and arrange support for any language you speak. As a member, you can file a grievance at any time.

You can also write a letter to tell us about your grievance. Anybody you trust can help you write the letter. Our address is:

Prestige Health Choice
P.O. Box 7368
London, KY 40742

What happens after you file a grievance

  • Prestige Health Choice will mail you a letter within five business days of receipt. This letter lets you know that we have received your grievance.
  • In some cases, getting information to help us review your grievance may take extra time. You can expect a resolution and a written answer from Prestige Health Choice within 90 days of receipt of your grievance. The time for deciding your grievance can be extended for 14 more days if the information we are waiting for could help with your grievance.

After we make a decision, we will mail you a notice (letter) with the following:

  • Our decision.
  • The date we made our decision.

Appeals

An appeal is the type of complaint you make when you want our plan to think about changing a decision we have made about a service or benefit that you or your provider has requested.

You must file your appeal within 60 calendar days from the date on the Notice of Adverse Benefit Determination (letter) we send you. You may file your appeal by phone or in writing. If you file your appeal by phone, you must send us a written, signed notice (appeal letter) within 10 calendar days of your phone call. We will use the date of your phone call as the start date for your appeal.

How to file an appeal

  • Print out and complete this appeal form (PDF). 
  • You can continue receiving services while we review your appeal. You may have to pay for services if your appeal is denied. 
  • You can ask us to extend the review time for your appeal by up to 14 calendar days if you have more information to help us decide. Call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856) to let us know.
  • Within 30 calendar days, Prestige Health Choice will resolve the issue. We will send you a Notice of Plan Appeal Resolution (letter) to let you know the result. If Prestige Health Choice needs more time to review your appeal, we will let you know in writing within two calendar days of the determination of the reason for the delay. We will tell you why we need to extend the review time.

An expedited (fast) appeal is what you request when you or your provider think your health is at risk, and a decision needs to be made in less than 30 calendar days. You or your provider may ask for an expedited appeal by calling 1-855-371-8078.

Prestige Health Choice will start to review your expedited appeal the day it is received. We will respond within 48 hours.

We will attempt to notify you of the decision by phone first. We will also mail you a Notice of Plan Appeal Resolution (letter) about the decision.

If you ask for an appeal to be expedited and we decide this is not needed, the appeal will be reviewed within the standard appeal time frame (30 calendar days). You will be informed by phone the same day we decide an expedited appeal is not needed. You will also receive a written notice (letter) within two calendar days if the time frame for your appeal has changed.

Send the appeal to:

Prestige Health Choice
P.O. Box 7368
London, KY 40742

You will not lose your Prestige Health Choice membership if you file an appeal. You will not lose your health care benefits if you file an appeal.

Appoint a representative

Privacy laws require a member’s written consent to allow someone other than the member to receive information regarding the member's care. You can appoint a representative to request an appeal or file a grievance by completing the Member Appointment of Representative Form (PDF).

Medicaid fair hearings

You can ask for a Medicaid fair hearing if you have gone through the Prestige Health Choice appeal process. Please note that Medikids members are not eligible to participate in the Medicaid fair hearing process.

You must request a fair hearing within 120 calendar days from the date on the notice (letter) of resolution for your appeal. With your written approval, you can pick someone to speak for you at the Medicaid fair hearing. The Medicaid fair hearing is with the Agency for Health Care Administration (AHCA).

The hearing office will make a decision based on rules and regulations, the facts produced during the hearing, and post-hearing submissions. A decision from a Medicaid fair hearing is final and cannot be appealed.

You can request a Medicaid fair hearing by writing to:

Agency for Health Care Administration Medicaid Hearing Unit
P.O. Box 60127
Ft. Myers, FL 33906

You can also request a Medicaid fair hearing by:

Medikids members — review by the state

Medikids members who do not agree with an appeal decision may request a review from the state. When you ask for a review, a hearing officer who works for the state reviews the decision made during the plan appeal.

You may ask for a review by the state any time up to 30 calendar days after you get the Notice of Plan Appeal Resolution. You must finish your plan appeal process first.

You may ask for a review by the state by writing to:

Agency for Health Care Administration Medicaid Hearing Unit
P.O. Box 60127
Ft. Myers, FL 33906

You can also request a review by the state by: