PHC Florida

Robert Heglar
AHF Provider

If You Have a Problem or Complaint

If you are ever unhappy with the service or care you get from PHC Florida, you should make a complaint to us.  We want you to be satisfied with the plan, our staff and our providers.  By making a complaint, you bring the problem you experienced to our attention so we can take action.  You help us become a better health plan.

A “complaint” is the lowest level of challenge and gives us a chance to fix a problem without it becoming a grievance.  Complaints must be resolved by the close of business the day following receipt.  If not, it is moved to the grievance system.

A “grievance” is an expression of dissatisfaction about any matter other than an “action.”  For example, you would file a grievance if you have a problem like:

  • The quality of your care
  • Waiting times for appointments
  • Waiting time to be seen while in a doctor’s office
  • The way your doctor or his or her staff behave
  • Unable to reach a provider or the managed care plan by phone
  • Inability to receive the information you need
  • Cleanliness or condition of a provider’s office.

An “action” is the denial or limit by the plan of services asked for by you or your provider.  Examples of an action are:

  • Changing level of service, i.e., outpatient instead of inpatient hospital care
  • Reduction, suspension or termination of a service that was already authorized for you
  • Denial of all or part of the payment for a service or failure to provide the service in a timely manner
  • The failure of the plan to act within ninety (90) days from the date it receives a grievance or forty-five (45) days from the date it receives an appeal.

An “appeal” is a request for a review of an action.  For example:

  • If we won’t cover or pay for services you think we should cover, you can file an appeal
  • If we or one of our contracted providers won’t give you a service you think should be covered, you can file an appeal
  • If we or one of our contracted providers cuts back on services you have been getting, you can file an appeal
  • If you think we are stopping your coverage of a service too soon, you can file an appeal

With your permission, a provider can file a grievance or appeal for you.

Read how to file a complaint or grievance.  If you want to appeal an action we made, read how to make an appeal. You can also read about how to ask for a Medicaid Fair Hearing.

 

AHCA 062614 PHC MMA Form 17.0