Provider Complaints and Disputes

Provider Grievances and Appeals

Providers have the right to file a dispute the Managed Care Plan’s policies, procedures or any aspect of a Managed Care Plan’s administrative functions, included proposed actions, claims/billing disputes and service authorizations.

Providers do not have appeal rights through the member plan appeals process.

How do Providers File a Complaint?

Vivida Health has dedicated staff for providers to contact via telephone, electronic mail, regular mail, or in person, to ask questions, file a provider compliant and resolve problems. Provider may contact Provider Services at 844-243-5175 to file a complaint. Complaints may also be submitted by mail at the address listed further below.

1. Non-Claim issues; Vivida shall:

  1. Allow providers forty-five (45) days to file a written Complaint.
  2. Within three (3) business days of receipt of a Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of resolution;
  3. Thoroughly investigate each provider Complaint using applicable statutory regulatory, contractual and provider agreement provisions, collection all pertinent facts from all parties and applying applicable plan written procedures;
  4. Provide written notice of the status to the provider every fifteen (15) days thereafter; and
  5. Resolve all Complaints within ninety (90) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution. Vivida shall maintain a complete and accurate record of all Complaints and shall make such records available upon request of the Agency.

2. Claim issues, in accordance with § 641.3155 Fla. Stat., Vivida shall:

  1. Allow providers ninety days (90) from the date of the final determination for the primary payer to file a written Complaint for claims issues;
  2. Within three (3) business days of receipt of a claim Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of resolution;
  3. Within fifteen (15) days of receipt of a claim Complaint, provider written notice of the status of the Complaint to the Agency and provider. For claims issues that require additional time to research, Vivida must submit a written notice to the Agency within three (3) business days of receipt of the Complaint and shall include:
    1. An explanation for the need of an extension; and
    2. Expected time needed beyond the fifteen (15) days for research and response.
    3. Approval is contingent upon Agency review.
    4. Vivida must provide written notice of the status to the provider every fifteen (15) days thereafter; and

(d) In accordance with § 641.3155, Fla. Stat., resolve all claims Complaints within sixty (60) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution.

In accordance with § 408.7057, Fla. Stat., Vivida Health will participate with the Agency’s contracted dispute resolution vendor for managing, addressing, and resolving provider complaints related to claim issues. The process shall be in compliance with § 641.3155, Fla. Stat.

Providers must return any overpayment to Vivida at the address set forth in this handbook within sixty (60) days after the date on which the overpayment was identified, and to notify Vivida in writing of the reason for the overpayment. (42 CFR 438.608 (d)(2)).

 

Submit Provider Complaints to:

 

Type of Appeal

 

Timing of Appeal

 

Address

Claims Payment Issues

Must be submitted within ninety (90) calendar days of last process date of claim.

6630 Orion Dr., Suite 203

Fort Myers, FL 33912

Non-Claims Issues

Must be submitted within forty-five (45) calendar days of last process date of claim.

6630 Orion Dr., Suite 203

Fort Myers, FL 33912

Contractual Issues

Must be submitted within ninety (90) calendar days of the occurrence of the contractual issue being appealed.

6630 Orion Dr., Suite 203

Fort Myers, FL 33912

Credentialing Denial or Credentialing or Quality Network Termination

Must be submitted within thirty (30) calendar days of the adverse benefit determination. Provider may request a hearing.

6630 Orion Dr., Suite 203

Fort Myers, FL 33912

Overpayment Recovery and Recoupment

Must be submitted within 60 calendar days from postmark date or electronic delivery date of

6630 Orion Dr., Suite 203

Fort Myers, FL 33912