Grievances and Appeals
Provider Appeals, Grievances, Reconsiderations, State Fair Hearings and EITPR Processes
Sunflower Health Plan wants to fully resolve your problems or concerns. Sunflower has steps for handling any problems you may have. You may request to be represented by legal counsel or another spokesperson when requesting a grievance, appeal, reconsideration, external independent third-party review or state fair hearing.
We offer all of our members and providers the following processes to achieve satisfaction:
- Grievance/Complaint Process
- Appeal Process
If you have additional questions about these processes, please call Customer Service at toll free 1-877-644-4623 TTY: 711. Interpretive services can be made available upon request. For information regarding member grievance/appeal processes, please refer to the Member Resources page.
A grievance is defined as any expression of dissatisfaction about any matter, other than an action that would be resolved through the appeals process. Grievances may include, but are not limited to: unclear and inaccurate information from staff, lack of action being taken on a case, the quality of care or services provided to a member, or any aspects of interpersonal business relationships such as the rudeness of a Sunflower employee, or failure to respect the member’s rights
- Sunflower will not treat you differently if you file a grievance.
- Filing a grievance will not affect your contract with Sunflower.
- Provider grievances can be filed verbally or in writing within 180 calendar days of the event being grieved.
- Non-participating providers are eligible to submit a grievance.
- For Sunflower to completely review your concern, please provide your first and last name, provider NPI, phone number where we can reach you, what you are unhappy with, and what you would like to happen when contacting us to file a grievance.
- Information or documents that support the grievance can be sent to Sunflower by mail or fax.
- Sunflower will resolve your grievance and send a resolution notice within 30 calendar days of receipt of the grievance.
Providers have the right to initiate the reconsideration step, which is optional, to have a decision made by Sunflower Health Plan reviewed.
Reconsideration Basics (optional step):
- Requests may be made by phone, email, in person or in writing to Sunflower or specialty partner address on EOP/letter.
- Include the claim number, reason for request, supporting documentation and other items requested.
- Must be requested within 120 calendar days of the date of the Notice of Action. Three additional calendar days will be allowed for mailing time.
- Reconsiderations will be resolved within 30 calendar days from the date of receipt and notification will be a revised EOP for same claim number.
- A provider may terminate the reconsideration process and submit an appeal request within 60 calendar days, plus an additional three calendar days for sending of the Notice of Action.
- If a provider does not submit an appeal request withing 63 calendar days of the Notice of Action, the provider must wait to receive the reconsideration resolution before filing an appeal.
Provider Appeal Basics:
- Sunflower will not treat you differently if you file an appeal.
- The provider will receive a written letter or EOP noting payment amount, denial, or adjustment and receive appeal instructions in that notification, this is the notice of action.
- Provider appeal request must be filed within 60 calendar days of the date of the notice action. Three additional calendar days will be allowed for mailing time.
- Information on how and where to appeal will be included in the EOP or notice of action you receive
- The member may not file a provider appeal.
- Providers may not charge Sunflower beneficiaries, or any financially responsible relative or representative of that individual, any amount in excess of the Sunflower paid amount. Section 1902(a) (25)(C) of the Social Security Act prohibits Sunflower providers from directly billing Sunflower beneficiaries.
- The provider may not balance bill a member.
- Information or documents that support the appeal can be sent by mail as noted in the notice of action or EOP.
- Sunflower will acknowledge appeal requests within 10 calendar days of receiving the request.
- Sunflower wants to resolve appeal concerns quickly and will resolve provider appeals within 30 calendar days of appeal request receipt.
- The provider will receive a notice of provider appeal resolution with the appeal decision, rationale, and date of resolution/decision
- If the appeal decision is not in the favor of the provider, the provider may not bill the member for services or payment denied by the plan in post-service appeals.
- A state fair hearing should only be requested after the provider has completed the Sunflower provider appeal process.
- The process for provider appeals and state fair hearings is the same for both participating and non-participating providers.
State Fair Hearing Basics:
- Providers can only file for a state fair hearing after completing the provider appeal process, with a determination received from Sunflower.
- Providers may request a state fair hearing within 120 calendar days of the date of the Provider Appeal Resolution Notice. Three additional calendar days will be allowed for mailing time.
- Requests for state fair hearing should be sent to the Office of Administrative Hearings (OAH) 1020 Kansas Avenue, Topeka, KS 66612
External Independent Third-Party Review (EITPR) Basics:
- Providers must submit the EITPR request in writing using the EITPR Request form available on Sunflower Health Plan's website. The form must be signed and completed entirely in order to be processed.
- Providers must submit this request within 60 calendar days from the date of the notice of appeal resolution. Three additional calendar days will be allowed for mailing time.
- Providers must complete the provider appeal step and receive a determination from Sunflower prior to requesting EITPR.
- Provider requests for an EITPR must involve a denial of an authorization for a new healthcare service or a denial of a claim for reimbursement. Authorization decisions that terminate, suspend, or reduce previously authorized services and qualify for continued services are not eligible for review by the external independent third-party reviewer.