Member Resources

Standard Payment Appeals

• An enrollee;
• An enrollee’s representative;
• Non-contract provider (see §50.1.1 for non-contract provider payment appeals);
• The legal representative of a deceased enrollee’s estate; or
• Any other provider or entity (other than the MA plan) determined to have an appealable interest in the proceeding.

Standard Pre-Service Appeals

• An enrollee;
• An enrollee’s representative;
• The enrollee’s treating physician acting on behalf of the enrollee or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider); or
• Any other provider or entity (other than the MA plan) determined to have an appealable interest in the proceeding.

Expedited Pre-Service Appeals

• An enrollee;
• An enrollee’s representative;
• Any physician or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider) acting on behalf of the enrollee.

Expedited (fast) and Standard appeal requests must be made within 60 calendar days from the date on the denial notice.

• Expedited requests can be made either orally or in writing.
• Standard appeal requests must be made in writing.

If a request for an appeal is filed beyond the sixty (60) calendar day time frame, without good cause, Simpra Advantage will dismiss your appeal request.

Once the Plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard requests or 60 calendar days for payment requests.

You, your representative, or your treating physician on your behalf can request an expedited (fast) appeal by phone or in writing and a standard appeal in writing directly to us at:

Mail:

Simpra Advantage
Appeals and Grievances Department
PO BOX 20648 
Tampa, FL 33622-0648

Call us to expedite an appeal at 1-844-637-4770 (TTY/TDD 1-833-312-0044)

Providers who are submitting more than 50 pages of documentation, please share files via CD (Compact Disc) or USB (Universal Serial Bus) drive.

Yes. If your health requires a quick response, you must ask for a “fast appeal”. Start by calling, writing, or faxing our Plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

You may file an expedited appeal by calling:

1-844-637-4770 (TTY/TDD 1-833-312-0044)

If Simpra Advantage decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Simpra Advantage will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request.

If Simpra Advantage denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the Plan by requesting a reconsideration.

A reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence, and findings upon which it was based, and any other evidence that the parties submit or that is obtained by the Plan, the current Quality Improvement Organization contracted by CMS, Acentra, or the independent review entity.

For more details on Acentra, the Quality Improvement Organization, please view your Plan’s Evidence of Coverage located in the documents section of the website.

You or your representative can request a standard or expedited reconsideration by writing directly to us at:

Mail:
Simpra Advantage
Appeals and Grievances Department
PO BOX 20648 
Tampa, FL 33622-0648

Contact Member Services Department at our toll-free number at:

1-844-637-4770 (TTY/TDD 1-833-312-0044)

Reconsideration requests must be filed with the Plan within 60 calendar days from the date of the notice of the organization’s determination.

Expedited requests can be made either orally or in writing.

Standard requests must be made in writing unless the enrollee’s Plan accepts oral requests. An enrollee should call the Plan or check his or her Evidence of Coverage to determine if the Plan accepts oral standard requests.

• An enrollee or an enrollee’s appointed or authorized representative may request a standard or expedited reconsideration.
• A non-contracted physician or provider to a Medicare Health Plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf.
• Non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.
• A physician regardless of whether the physician is affiliated with the Plan may request that a Medicare Health Plan expedite a reconsideration.

Contracted providers do not have appeal rights.

We will review your appeal. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of Simpra Advantage. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

A good cause exception is acceptance of request for a standard determination that was filed late. Simpra Advantage will consider the circumstance that kept the enrollee or representative from making the request on time and whether any organizational actions might have misled the enrollee.

Examples of circumstances where good cause may exist to file a late appeal include (but are not limited to) the following situations:

• The enrollee did not personally receive the adverse organization determination notice, or he/she received it late;
• The enrollee was seriously ill, which prevented a timely appeal;
• There was a death or serious illness in the enrollee’s immediate family;
• An accident caused important records to be destroyed;
• Documentation was difficult to locate within the time limits;
• The enrollee had incorrect or incomplete information concerning the reconsideration process; or
• The enrollee lacked the capacity to understand the time frame for filing a request for reconsideration.