Medicare Advantage Medical Authorizations, Appeals, and Grievances

Find information about Medicare Advantage medical exceptions and appeals, including how to request coverage decisions, file appeals, and understand the review process.

Covered medical services and prior authorizations

Your Evidence of Coverage will list the services that are covered and indicate which services require prior authorization.

Should your medical service require prior authorization (also called an Organization Determination), you, your doctor, or your representative can send us a request. Please make sure that you include any clinical information to support this request. The request can be faxed to 1.855.328.0059 or sent by mail to:

Health First Health Plans
Attn: Medical Authorizations
6450 US Highway 1
Rockledge, FL 32955

To contact us by phone, please call toll-free at 1.800.716.7737 weekdays from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to noon. TDD/TTY Relay users can also contact us at 1.800.955.8771 during the same hours.

Your Evidence of Coverage will list the services that are not covered (exclusions). 

A physician's statement indicating why the medical service is medically necessary, in addition to clinical documentation supporting the request.

It will be reviewed by a Medical Director, and a decision will be based on clinical evidence and your unique medical condition.

A decision will be made as soon as required for your medical condition but no later than 7 days for complete standard requests, and 72 hours (3 days) if the standard timeframe could jeopardize your health. Your doctor should indicate if the fast timeframe is warranted, and the decision will be made in 72 hours. Contact a Customer Service Representative to find out the status of your request.

If the authorization is approved, you and your doctor will receive an approval letter indicating the authorization number and length of coverage. If the request is denied, you and your doctor will receive a denial letter indicating the reason for the decision and how to appeal it if you choose.

If an authorization for medical services is approved, you will be responsible for the cost-share for the requested service as listed in your Evidence of Coverage.

Appeals

If your request for coverage of medical care is denied, you or your authorized representative can file an appeal by writing to us within 65 days from the denial, telling us why you believe the decision was incorrect. If the situation is urgent and you need a decision quickly, your doctor will automatically be considered your authorized representative and can appeal on your behalf. Expedited appeals will be accepted in writing, or verbally by contacting a Customer Service Representative. If the appeal is not urgent, you can file a written appeal, or authorize someone to act on your behalf in writing. For more information, please call us toll-free at 1.800.716.7737 weekdays from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to noon, or though TDD/TTY Relay at 1.800.955.8771. You can also fax your appeal to 1.855.328.0053. Pre-service appeals will be decided within 30 days unless your medical condition warrants an expedited timeframe, in which the appeal will be decided within 72 hours. We may make a 14 day extension if we need time to gather information that benefits you. Appeals for services that have already been received will be decided within 60 days. You will have the right to an external review if the decision is still not in your favor.

Grievances

If you are dissatisfied with any aspect of your plan, including a decision not to expedite a coverage decision for you, you can file a grievance within 60 days of the incident. We hope that you will call us first about your concern, but if we cannot resolve it for you immediately, you can also send a written grievance along with supporting information to:

Health First Health Plans
Attn: Appeals Coordinator
6450 US Highway 1
Rockledge, FL 32955

To contact us by phone, please call Customer Service toll-free at 1.800.716.7737 weekdays from 8 a.m. to 8 p.m. and Saturday from 8 a.m. to noon. From October 1 to March 31, we're available seven days a week from 8 a.m. to 8 p.m. (TTY: 1.800.955.8771 during the same hours. You can also fax your grievances to 1-855-328-0053.

Appropriate people at Health First Health Plans will investigate your concern and advise you of the outcome of the review within 30 days, unless a 14-day extension is warranted. Your satisfaction is our greatest concern and we will do everything possible to ensure you are treated fairly.

You can file a grievance with Health First Health Plans as described above, and can also file your grievance with the Florida Quality Improvement Organizations (QIO) by contacting them at:

Acentra Health
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
Toll-free number: 1.888.317.0751
Fax number: 1.844.878.7921

Other Appeals and Grievances Information

Please contact Customer Service Representatives for information related to the aggregate number of appeals, grievances, and exceptions filed with the Plan, and for information regarding the process or status of your case.

How to contact Medicare

Customer Service Representatives are dedicated to personally solving any problems you may have with us and our providers to your full satisfaction. If you prefer to contact the Centers for Medicare and Medicaid Services (CMS) directly, please visit Medicare's web site:

Also, the Evidence of Coverage (EOC) includes more details about grievances, coverage determinations, appeals procedures, and exceptions in Chapter 9, and your rights and responsibilities upon disenrollment are listed in Chapter 8.

How to appoint a representative

If you want to name someone (such as a relative, friend, advocate, doctor, lawyer, or anyone else) to handle appeals and grievances with us on your behalf, the person you name would be your appointed representative. You can use this form:

Appointment of representation form English I Spanish

If you want to give someone permission to access your personal health information (for example claims, medical, or financial information) please use this form:
Authorization to disclose your Protected Health Information (PHI) form

Please send your completed form(s) to us at:

Health First Health Plans
6450 US Highway 1
Rockledge, FL 32955

Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

 Y0089_EL110251_M  | Accepted date: 10/01/2025
Last updated: 10/01/2025