AHCA Medicaid Provider Complaint Process Update
Monday, April 22, 2019
Posted by: Kyle Simon
The Florida Agency for Health Care Administration (AHCA) on April 12 made an announcement regarding the process by which all Medicaid providers may submit a complaint about health and dental plans in order to dispute plan policies, procedures, or any aspect of a plan’s administrative functions, including proposed actions, claims/billing disputes, and service authorizations.
Each plan’s provider handbook includes specific instructions about how to contact the plan to file a provider complaint and information about the complaint review process. This information is also available to non-participating providers upon request.
Plans must accept, acknowledge, and thoroughly investigate all provider complaints and provide written notice of disposition. Plans must also maintain a complete and accurate record of all complaints and submit a provider complaint report to AHCA on a monthly basis.
To obtain more information about the contractual requirements surrounding the provider complaint process, click here and select 2018-2023 SMMC Plan Model Contract under Health Plans.
To obtain plan-specific provider complaint contact information, click here and select Plan Complaint Contacts for Providers.
If you are unable to address your issue via the plan’s provider complaint process, you may submit a complaint to AHCA online using the Florida Medicaid Complaint Form. Please be sure to select the corresponding plan name when prompted. You may also file a complaint by phone, by calling the Medicaid Helpline at (877) 254-1055 (TDD 1-866-467-4970). Staff are available to assist you Monday through Friday, 8:00 a.m. to 5:00 p.m. ET.