Filing an Appeal

Appeal Process

An appeal is when you ask Sunflower to review a decision we made. This decision could be a denial, a limit on your service, or a delay in providing service. An appeal is your request for Sunflower to look at our decision again. You can ask us to check new or extra documents and make a new decision. You can ask for this review by phone or in writing. You cannot appeal a payment issue with a provider. If you get a bill from a provider, contact Sunflower for help. The appeal process is the same for everyone. We won’t treat you differently if you file an appeal.

Key Points:

• Appeals for Value-Added Services: You cannot appeal issues with Value-Added Benefits.
• Filing an Appeal: You must file an appeal within 60 calendar days of the date on the letter that tells you about the decision. You get three additional calendar days for mailing time. This letter may be called “Notice of Adverse Benefit Determination.” If you’re not sure if the letter is about a decision, call us to check.
• How to Appeal: You can file an appeal by phone, fax or in writing. The letter about the decision will also tell you how to appeal.
• Getting Help: You can have someone, like a family member, provider, or a lawyer file an appeal for you. You need to sign a form to let them do this. We will send this form with the Notice of Adverse Benefit Determination or you can get it from Customer Service or our website. You must fill it out and return it by mail or fax before Sunflower can work with the person you name.
• Supporting Documents: Send any information or documents supporting the appeal to Sunflower by mail or fax.
• Help with Forms: Sunflower can help you fill out any forms you need.
• Resolution Time: Sunflower wants to fix your problem quickly. We will resolve your appeal within 30 calendar days. If we need more time, we can ask for up to 14 more calendar days. We use that time to gather more information to help you. We will tell you in writing and try to call you if we need more time. You have the right to file a grievance if you disagree with the decision to extend an appeal timeframe. You or your provider can also ask for more time. Requests for more time must be made two business days before the 30-calendar-day deadline. If Sunflower cannot meet the deadline, you can ask for a State Fair Hearing.

Expedited Appeals

If your health is at immediate risk, you can ask for a fast review. Sunflower will decide on these within 72 hours. You don’t need to submit it in writing. Sunflower will try to call you with the appeal decision. If the situation is not actually urgent, we may change it to a standard appeal. We will try to call and let you know that the expedited appeal will be handled in the standard timeframe. We will also send you a letter within two calendar days saying the appeal timeframe is standard. We will resolve standard appeals within 30 calendar days.

Request Documents

You can ask for copies of the documents we used to decide on your appeal. Sunflower will give these to you for free. Call Sunflower toll free 1-877-644-4623 as soon as you can if you want these documents before we make a decision on your appeal.

Send Appeals To:

Sunflower Health Plan
Appeals & Grievances
P.O. Box 10287
Van Nuys, CA 91410-0287
Phone: 1-877-644-4623, TTY 711
Fax: 1-888-453-4755

Interpretive services are available upon request.