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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, you can call Member Services at 1-855-355-9800 (TTY/TDD 1-855-358-5856) any time and a representative will answer your questions and/or concerns.

Prestige Health Choice (Prestige) is here to help you.

A complaint is a concern or problem you have that is related to your coverage or care. If you make a complaint, Prestige 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 2 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 1 of our providers. Possible subjects for grievances include:

  • Quality of care.
  • Quality of services provided.
  • Lack of respect for your rights as an enrollee.

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, 7 days a week. We will help you understand the process and arrange support for any language you speak. As an enrollee, you are able to 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 will mail you a letter within 5 business days to let you know we have received your grievance.
  • Prestige will make a decision on your grievance within 90 calendar days from the day we receive it.
  • You can ask us to extend the review time for your grievance 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.
  • If we need more time to review your grievance, we will let you know in writing within 2 calendar days of the determination of the reason for the delay. We will tell you the reason why we need more time to review your grievance. We will make a decision about your grievance within the next 14 calendar days.

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 have requested.

You must file your appeal within 60 calendar days from the date on the notice (letter) you receive. 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 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 for 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 will resolve the issue. We will send you a letter to let you know the result. If Prestige needs more time to review your appeal, we will let you know in writing within 2 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 will start to review your expedited appeal the day it is received. We will make a decision within 72 hours of receiving your request. We will attempt to notify you of the decision by phone first. We will also mail you a notice 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 days). You will be informed by phone the same day we decide an expedited appeal is not needed. You will also receive a written letter within 2 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 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 the member’s written consent in order to allow someone other than the member to receive information regarding the care that is at question. You can appoint a representative to request an appeal or file a grievance by completing the Member Appointment of Representative form.

Medicaid fair hearings

You can ask for a Medicaid fair hearing if you have gone through the Prestige 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:
Calling 1-877-254-1055.
Faxing 1-239-338-2642.
Emailing ACHA

Appealing a decision to the Subscriber Assistance Program (SAP)

If you have completed the Prestige appeal process and you are still unhappy, you can appeal to the Subscriber Assistance Program (SAP). The SAP is a committee run by the state of Florida.

You must complete the appeal process with Prestige before you can submit your appeal to the SAP. You must submit your appeal to the SAP within 1 year after getting the decision notice (letter) from Prestige.

If you have already gone through a Medicaid fair hearing, you cannot appeal to the SAP.

You can write to:

Agency for Health Care Administration
Subscriber Assistance Program
Building 3, MS #45
2727 Mahan Drive
Tallahassee, Florida 32308

You can also call the SAP at 1-850-412-4502 or toll free at 1-888-419-3456