Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Standard VI: Provider Services
CC- IV.A.11.f
CONTRACT
SECTION
9. Answering
Messages on Help
Line
CC- IV.A.11.g
10. After Hours
Coverage
CC-VII.I.4.e
11. Provider
Complaint System
CC-VII.I.5.a
12. Provider
Complaint System
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
c. Blocked call rate does not exceed
1%.
d. Rate of abandoned calls does not
exceed 5%.
A health plan representative responds to
messages on the next business day.
The health plan ensures that after regular
business hours, the provider services line
(not the prior authorization line) is
answered by an automated system with
the capability to provide callers with
information about operating hours and
instructions about how to verify
enrollment for an enrollee with an
emergency or urgent medical condition.
The health plan establishes and maintains
a provider complaint system that permits
a provider to dispute the health plan’s
policies, procedures, or any aspect of the
health plan’s administrative functions,
including proposed actions and claims.
The health plan:
a. Distributes the provider complaint
system policies and procedures,
including claims issues, to out-ofnetwork
providers upon request.
b. May distribute a summary of these
policies and procedures, if the
Yes
No
Yes
No
Yes
No
a. Yes
No
N/A
b. Yes
No
N/A
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VI_F2_07_11
Page 4
FINDINGS