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

Standard XI: Grievances and Appeals
AGENCY FOR HEALTHCARE ADMINISTRATION
MANAGED CARE ORGANIZATIONS
Compliance Monitoring Tool with Specific Contract Standards
CONTRACT SECTION CONTRACT REQUIREMENT COMPLIANT SCORING
5. State-level Appeals
CC-IX.A.5
6. Grievance/Appeals
Reports
CC-IX.A.7
7. Log of Complaints
CC-IX.A.8
8. Written
Acknowledgment
CC-IX.A.9
9. Decision-making by
People not Previously
Involved
CC-IX.A.10
10. Personnel Involved in
Grievances and
Appeals
The health plan’s grievance system
includes information for enrollees on
seeking a state level appeal through
either the Subscriber Assistance Panel
(for HMOs) or the Beneficiary
Assistance Panel (for PSNs).
The health plan maintains a record of
grievances and appeals and submit
reports to BMHC.
The health plan keeps a log of
complaints that do not become
grievances, including date, name,
nature of complaint and disposition.
The plan submits the report upon
request of the Agency.
The health plan acknowledges, in
writing, receipt of each grievance and
appeal, unless the enrollee requests an
expedited resolution.
The health plan ensures that none of
the decision makers on a grievance or
appeal were involved in any of the
previous levels of review or decisionmaking.
The health plan ensures that all
decision makers are health care
professionals with clinical expertise in
treating the enrollee’s condition or
disease when deciding:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
a. Yes
No
b. Yes
No
c. Yes
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
Met
Partially Met
Not Met
DOCUMENTS
REVIEWED
FINDINGS
State of Florida Compliance Monitoring_Standard_XI_F2_07_11
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