By ICA staff

(From the September/November issue of Advocate’s Advice, a publication by Insurance Consumer Advocate Sean Shaw)

If you are insured through a managed care plan such as a health maintenance organization (HMO), an exclusive provider organization (EPO), a prepaid health clinic (PHC) or a prepaid health plan (PHP), you have special rights. These rights come into play when claims or medical services are denied by your managed care plan.

Your managed care plan is required by law to notify you of your appeal rights and procedures when service or care is denied. First, you can file an appeal with the plan itself. There is usually a two level appeal process. Once you have completed the plan’s internal appeal process, if you are still not satisfied, you may request an informal hearing with the Subscriber Assistance Panel (SAP). The SAP is a panel of various state agency representatives who will review your case and provide a recommendation to either the Agency for Health Care Administration (AHCA), or the Office of Insurance Regulation (OIR) regarding what action, if any, the plan must take to comply with its duties to you.

The SAP is designed to provide consumers of managed care plans with an additional grievance process if there has not been a satisfactory resolution through the plan’s internal process.

Arising from legislation first enacted in 1985 and contained in Section 408.7056, Florida Statutes, the SAP is comprised of the Insurance Consumer Advocate, or designee; two members employed by AHCA; two employed by the Department of Financial Services (DFS); a physician appointed by the Governor; and a consumer representative appointed by the Governor. If it is determined to be necessary, physicians with relevant expertise to the case may also be included. The SAP schedules hearings, generally on a weekly basis, to hear cases that have met the criteria for hearing and have not been settled.

Please note that the SAP process is not available to people insured under traditional health insurance policies or federal programs such as Medicare. Nor is it available for disputes in which a lawsuit has been filed.

Subscribers of managed care plans have 365 days from notification of a plan’s final determination to deny services to file an appeal with the SAP. The process begins when a subscriber submits a complete Request for Review and Release Form along with pertinent information to AHCA. The managed care plan then submits its grievance file, medical records and the subscriber’s managed care contract. AHCA reviews the documentation and, if appropriate, prepares the case for hearing.

If a grievance is scheduled for a SAP hearing, it will be conducted via teleconference. Subscribers may have another participant (attorney, physician, family member, etc.) to help in the presentation. A court reporter attends all hearings. Transcripts are available, at a cost, from the court reporter. The SAP reviews all the documentation provided by both the subscriber and the managed care plan prior to the hearing and may ask questions of the participants. The subscriber will have 15 minutes to present their case, followed by 15 minutes for the managed care plan. The presentations may or may not be followed by questions from the SAP. Finally, there is a 5 minute rebuttal period, beginning with the managed care plan and ending with the subscriber. The SAP hearings are usually closed to the public due to the sensitive medical information being discussed.

It is important for subscribers to be familiar with their contract and understand that most contracts allow the managed care plan to deny coverage for a particular medical service or treatment if the plan determines that the service or treatment is not medically necessary. If a contract specifically excludes a service, medical necessity generally does not have a bearing in the case.

Here are some tips to improve your chances at a SAP hearing:
  • Provide as many medical records as possible that pertain to the appeal, including physician(s) justification for the service in question.
  • Identify the section in the managed care contract that indicates a service should be covered.
  • Have documentation including names and dates, of all conversations with the managed care plan and with the providers.
  • Present the case in a chronological order of events.
  • Listen to the managed care plans presentation, list the issues in which you disagree and address them during the 5 minute rebuttal time.

The SAP also has procedures in place to address emergency situations. If you believe you are in an emergency situation, you must mention the need for an expedited hearing to the staff when contacting them. The SAP staff then determines whether the situation qualifies for an expedited hearing.

Within 15 working days following the hearing, the SAP will issue its recommendation to the subscriber and AHCA or OIR. Within 10 days after receipt of the SAP’s written recommendation, the parties may furnish to AHCA or OIR evidence of opposition to the recommendation or findings of fact. All parties will be notified in writing of the final determination by AHCA or OIR within 30 days of the SAP’s written recommendation.

The Subscriber Assistance Panel must complete the process within 165 days however, the process usually takes much less time. If the managed care plan disagrees with the SAP’s decision, it has the right to an administrative hearing under Section 120.574, Florida Statutes. A subscriber who disagrees may choose to go through the judicial process.

For more information on the Subscriber Assistance Panel call 1-888-419-3456, or visit their website: http://www.ahca.myflorida.com/MCHQ/Consumer/SPSAP/index.shtml.