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

Standard VI: Provider Services
CC-VII.I.5.c
CONTRACT
SECTION
13. Provider
Complaint System
CC-VII.I.5.d
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT REQUIREMENT COMPLIANT SCORING
summary includes information about
how the provider may access the full
policies and procedures on the health
plan’s website; and the summary also
details how the provider can request
a hard copy from the health plan at
no charge.
The provider complaint system:
a. Includes a dedicated staff for
providers to contact via telephone,
electronic mail, regular mail, or in
person, to ask questions, file a
provider complaint and resolve
problems.
b. Identifies a staff person specifically
designated to receive and process
provider complaints.
c. Allows providers 45 calendar days to
file a written complaint for issues
that are not about claims.
d. Investigates each provider complaint
using applicable statutory,
regulatory, contractual and provider
contract provisions, collecting all
pertinent facts from all parties and
applying the health plan’s written
policies and procedures.
e. Ensures that health plan executives
with the authority to require
corrective action are involved in the
provider complaint process.
a. Yes
No
b. Yes
No
c. Yes
No
d.Yes
No
e.Yes
No
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
State of Florida Compliance Monitoring_Standard_VI_F2_07_11
Page 5
FINDINGS