PHC Florida

Robert Heglar
AHF Provider

Making an Appeal

You can appeal an action by PHC Florida within 60 calendar days from the day you got our notice of adverse benefit determination.

You can appeal orally or in writing.  Oral appeals must be followed by a written, signed appeal within ten (10) calendar days of when you make the oral appeal.  Member Services can help you with this if you want.  We will send you a notice to remind you that you must file a written appeal within ten (10) calendar days of getting your oral appeal.  Your doctor can appeal for you with your written permission.

Our timeframe to resolve your appeal begins on the date we get your written or oral appeal.  We will send you a letter telling you that we got your appeal within five (5) business days of receipt.

We will resolve your appeal within 30 calendar days from the date that we got your appeal, unless you have asked for an expedited or “fast” appeal.  This timeframe can be extended up to 14 calendar days if you ask for it.  Or we can extend the timeframe if we need more time to get more information that would be better for your appeal.  If we need more time, we will call you and tell you why the same day we decide we need more time. We will also send you written notice telling you why we need more time.  We will send this within two (2) calendar days from the day when we decided we need more time.

You can ask for a fast appeal if the time it takes for a standard decision could harm your health.

You can make a fast appeal orally or in writing.  Your doctor can file one for you with your written permission.  If you make an oral fast appeal, you do not need to follow it up in writing.

If you make a fast appeal, we will give you an answer within 72 hours after we get your appeal.  We will call you to tell you our decision by the close of business the day we make the decision.  We will also send you a letter about our decision within two (2) calendar days.

If we say “no” to your request for a fast appeal, we will answer your appeal using the standard timelines described above.  We will call you to tell you if we say “no” to your fast appeal request.  We will also send you a letter telling why we said “no” to your fast appeal request within two (2) calendar days.

If the decision to your appeal is in your favor, we will provide the services or prescription drugs as quickly as your health requires.  If our decision to your appeal is not in your favor, you can ask for a Medicaid Fair Hearing.

If you want to appeal, need help with your written appeal or have questions, call Member Services.  Send your written appeal to Member Services.  You can also fax your appeal to Member Services.

For more information about the appeals process, look in the Enrollee Handbook (effective March 1, 2017).  See Chapter 10.


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AHCA 062614 PHC MMA Form 17.0