It is important to submit your appeal within 60 calendar days of receiving the denial notice. The rules regarding Medicaid fair hearings dictate that requests must be made within 120 days if the appeal is denied. Ensure you are aware of any specific timelines as details may vary based on individual circumstances.

The purpose of this form is to provide a clear and structured process for members of Simply Healthcare Plans to appeal a denial of services. It aims to ensure members can seek reconsideration of decisions that adversely affect their healthcare. By submitting this appeal, members assert their rights to necessary medical services.

• 1. Personal Information: Basic details including name, contact number, and address.
• 2. Service Denied: Details regarding the service that was denied and the date of the notice.
• 3. Reason for Appeal: A section where members can specify the reasons for their appeal.
• 4. Supporting Documents: Area for attaching or listing any supporting medical documents.
• 5. Member Signature: A signature field to validate the appeal request.

Failure to submit this form may result in the loss of the opportunity to appeal a decision made by Simply Healthcare Plans. Consequently, necessary medical services may be denied without further recourse. It is vital for members to adhere to the submission guidelines and timelines outlined.

• Loss of Service: Not appealing in time can lead to losing access to necessary medical services.
• Adverse Health Effects: Delay in service can adversely impact health outcomes.
• Financial Consequences: Members may incur costs if services are continued without a valid appeal.

• 1. Service Denial: Use this form if your service request has been denied.
• 2. Request for Reconsideration: When you disagree with the adverse determination, this form is necessary.
• 3. Clarification on Services: Members who need further details on the denial can submit via this form.